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Core Curriculum Outline for Rheumatology Fellowship
Programs
A Competency-Based Guide to Curriculum Development
March 2006
CONTENTS
Introduction ................................................................................. 1
How to Use this Curriculum Outline..........................................2
I.
Medical Knowledge............................................................. 4
II.
Patient Care .......................................................................19
III.
Practice-based Learning and Improvement ................... 25
IV. Systems-based Practice................................................... 28
V.
Interpersonal and Communications Skills ..................... 33
VI. Professionalism ................................................................36
Appendices
A.
The Competencies in a Specialized Clinic or Rotation .42
B.
Example of a Section of a Competency Based
Curriculum ......................................................................... 45
C. Sample Curriculum Activity and Evaluation Grid............ 49
D.
Suggested Evaluation Tools ............................................ 58
E.
Pediatric Rheumatology Supplement .............................59
F.
Curriculum Reference Resources ................................... 64
1
Introduction
The subspecialty of rheumatology includes a wide array of inflammatory, non-
inflammatory, and degenerative diseases that affect the musculoskeletal and other
organ systems. The purpose of rheumatology training programs is to train fellows to be
accomplished practitioners and consultants in the rheumatic diseases, as well as
encourage the professional and scholarly attitudes and approaches of a competent sub-
specialist that are needed to maintain an understanding of current concepts in
rheumatology as advances occur.
This Core Curriculum Outline is a substantial and comprehensive revision of the
previous ACR Core Curriculum Outline for Program Directors that is designed to reflect
the importance of competency-based training and assessment in graduate medical
education, as defined by the Accreditation Council for Graduate Medical Education
(ACGME), and to emphasize the six general competencies. These are:
Medical Knowledge
Patient Care
Practice-based Learning and Improvement
Systems-based Practice
Interpersonal and Communications Skills
Professionalism
The revised curriculum outline is organized by these competencies. The prior version of
the core curriculum outline was divided into two major sections of Basic Science and
Clinical Science. The factual components of both of these areas are now incorporated
into the Medical Knowledge section. The clinical aspects of these areas now reside in
the Patient Care section. Those aspects of the core curriculum that pertain to
communication and professionalism have been expanded into individual major sections.
The general competencies of Practice-based Learning and Improvement and Systems-
based Practice are an integral part of the current practice of rheumatology and are
already largely incorporated in rheumatology training programs.
The purpose of
specifically highlighting these in the core curriculum outline, as for the other
competencies, is to clarify their essential components, describe how and where they are
acquired in the course of fellowship training, set benchmarks or markers of performance
expected of the trainee, and suggest some of the tools that can be used to measure that
performance.
The revised curriculum outline has also been significantly expanded in the area of
pediatric rheumatology. The ACGME suggests that “programs with the qualified faculty
and facilities provide training in pediatric rheumatic disease.” The ACR recognizes that,
because of the worldwide shortage of pediatric rheumatologists, many internist
rheumatologists in clinical practice will be called upon to evaluate and treat children.
The core curriculum reflects the goal of the ACR that every rheumatology fellow have
familiarity with pediatric rheumatic diseases, whether or not they have the opportunity to
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rotate through a pediatric rheumatology clinic. Because reading is no substitute for
direct experience, training programs are encouraged to find opportunities for their
fellows to see patients in a pediatric rheumatology clinic. However, because many will
not have the opportunity to spend time in a pediatric rheumatology clinic, the curriculum
now emphasizes a minimum set of core knowledge in pediatric rheumatology for the
adult trainee.
To further this end, Appendix E provides more detailed pediatric
rheumatology information and a suggested reading list.
This outline is consistent with the requirements of the Residency Review Committee for
training in rheumatology and serves as a guide for (1) Training Program Directors and
fellows in meeting the requirements of the Residency Review Committee, (2) the ACR
Reading List Subcommittee, and (3) the ACR Continuing Education Committee.
The Core Curriculum Outline is also meant to provide a detailed guide for Training
Program Directors to use in the development of their own individual fellowship training
curriculum.
This outline presents a comprehensive view of the components of a
competency-based training program in rheumatology.
However, individual training
programs will develop their own curricula that reflect their particular areas of expertise
and resources.
This document is meant to be a practical resource for Program
Directors to provide detailed descriptions of general competencies in rheumatology and
provide suggestions for performance markers and assessments in these areas. To
further this goal, additional appendices are provided which contain practical examples of
competency-based clinical training, samples of methods for documenting competency-
based training, and detailed reference resources.
How to Use this Curriculum Outline
A significant hurdle in the transition to a competency-based curriculum is the
development of the language to describe these competencies. Much of this language is
presented in the Curriculum Outline to be incorporated by the Program Director into an
individual curriculum. The Outline divides each competency section into six sections. A
Definition of the competency in the context of rheumatology training is provided. The
Essential Components of each competency are then listed and described. These
components can be used to provide the rationale for a given training activity.
Suggested Methods of Acquisition of the competency are listed. These are the specific
kinds of activities and methods by which trainees can acquire a specific competency.
Of course this acquisition is not a passive activity and many of these methods require
active planning and teaching by supervising physicians, as well as active learning by
fellows.
Many of the same acquisition or instructional methods are used for the
development of different competencies, and a program may use different or additional
methods than those suggested. Important Performance Markers for each essential
component of a competency are listed. These markers of performance, or benchmarks,
are the same as the Educational Goals.
A list of suggested Evaluation Tools to
measure this performance is also presented for each competency. These generic
evaluation tools can be modified to include assessment of the specific performance
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markers of a given competency. Again, an individual program may use some or others
of these tools. Finally, a short list of References is given for additional detail and
resources on each competency.
Documentation of a competency-based curriculum involves describing how the training
program works to develop and assess the six general competencies in its trainees
during the course of the fellowship training program. How the training and educational
experiences are structured, which methods are used to evaluate the development of
competency and the means by which the Program Director documents the curriculum
are all at the discretion of the individual fellowship program and may vary widely from
program to program. Several appendices have been included to provide examples of
methods that can be used to develop and document a competency-based curriculum.
Appendix A illustrates how the general competencies are developed in a typical
rheumatology clinical experience or rotation. Appendix B is an example of a section of
competency-based curriculum in narrative form. An alternative method of documenting
a competency-based curriculum in grid or table form is presented in Appendix C. A
description of Evaluation Methods is included in Appendix D. Sources for more detailed
information on all of the general competencies are included in Appendix F.
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I.
Medical Knowledge
The subspecialty of rheumatology includes a wide array of autoimmune, inflammatory,
and degenerative diseases that affect the musculoskeletal and other organ systems. A
working knowledge of the basic and clinical sciences that relate to musculoskeletal and
rheumatic disease is fundamental to the practice of rheumatology. Understanding of
normal and pathogenic processes of the immune system form the basis of reliable
diagnosis and the development and use of an increasingly sophisticated range of
immunomodulatory treatments for the rheumatic diseases. Similarly, knowledge of the
basis for and use of laboratory tests of immune activity is a principal asset of the
practicing rheumatologist.
Rheumatology trainees must also have practical
understanding of the approaches and modalities used by other specialists and allied
health professionals for the treatment of rheumatic diseases in order to manage the
care of their patients effectively. Training programs must teach and emphasize the
cognitive skills that are necessary to apply this detailed knowledge to problem solving
for diagnosis, treatment and research of the rheumatic diseases.
Definition
Medical knowledge refers to the understanding of established and evolving biomedical,
clinical, and cognate sciences, and to the application of this knowledge to patient care.
Essential Components
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Basic Sciences
A. Anatomy and biology of musculoskeletal tissues: for each tissue, understand
the embryology, development, biochemistry and metabolism, structure,
function, and classification.
1. Connective tissue cells and components: fibroblasts, collagens,
proteoglycans, elastin, matrix glycoproteins
2. Joints and ligaments: diarthrodial joints, intervertebral discs, synovium,
cartilage
3. Bone: development, structure, cellular basis of turnover and
remodeling, hormonal and cytokine regulation
4. Muscle and tendons
5. Blood vessels
B. Immunology
1. Anatomy and cellular elements of the immune system
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a. Lymphoid organs: gross and microscopic anatomy, structure
and function
b. Organization of the immune system: innate and adaptive
immune systems
c. Specific cells: for each cell type, understand the ontogeny,
structure, phenotype, function, and major activation
markers/receptors.
(1) Lymphocytes: T cells and B cells (naive, memory,
activated, regulatory)
(2) Antigen presenting cells: dendritic cells, monocytes and
macrophages
(3) Natural killer cells
(4) Neutrophils and eosinophils
(5) Other cells: NKT cells, mast cells, endothelial cells,
platelets, fibroblasts
2. Immune and inflammatory mechanisms
a. Antibody structure and genetic basis of antibody diversity
b. Receptor/ligand interactions: activating and inhibiting receptors,
signal transduction, complement receptors, Fc receptors, toll
receptors, adhesion molecules
c. Molecular basis of T cell antigen recognition and activation.
d. B cell receptors: structure, function, antigen binding, effector
functions
e. Antigens: types, structure, processing, presentation, and
elimination. Superantigens: types, site of binding, and effects
on immune system
f. Major histocompatibility complex: structure, function,
nomenclature, and immunogenetics
g. Major immune cell signaling pathways
h. Complement/Kinin systems: structure, function, and regulation
i. Acute phase reactants and enzymatic defenses
3. Cellular interactions and immunomodulation
a. Cellular activation and regulation: for each cell type, understand
mechanisms of activation and suppression of function (e.g. T
cell:B cell interactions via CD28:CD80/86).
b. Cytokines: for each cytokine, understand the origin, structure,
effect, site of action, metabolism, regulation, and gene
activation.
c. Immune cell trafficking; adhesion molecules, chemokines
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d. Inflammatory mediators: for each mediator, understand the
origin, structure, effect, site of action, metabolism, and
regulation.
4. Immune responses
a. Antibody-mediated: opsonization, complement fixation, and
antibody dependent cellular cytotoxicity
b. Cell-mediated: cells and effector mechanisms in cellular
cytotoxicity and granuloma formation
c. IgE-mediated: acute and late - phase reactions
d. Mucosal immunity: interactions between gut and bronchus-
associated lymphoid tissue and secretory IgA
e. Innate immune responses: natural killer cells, pattern
recognition, interaction with adaptive responses
f. Pathologic immune responses: Immune complex-mediated
(physicochemical properties and clearance of immune
complexes), graft versus host response, abnormal apoptosis
5. Immunoregulation
a. Tolerance: mechanisms of central and peripheral tolerance,
including clonal selection, deletion, and anergy
b. Cell-cell interactions: help and suppression. Understand the
collaboration among cells for control of the immune response.
c. Idiotype networks: inhibition and stimulation
C. Purine and uric acid metabolism
1. Purine: biochemistry, synthesis, and regulation
2. Uric acid: origin, elimination, and physicochemical properties
3. Crystals: factors affecting formation, induction of inflammation
4. Purine pathway enzyme deficiencies and immunodeficiency: ADA,
PNP
D. Biomechanics of bones, joints, and muscles: understand the principles of
kinesiology of peripheral/axial joints and gait and how alterations in
biomechanics contribute to musculoskeletal disorders.
E. Neurobiology of Pain
1. Peripheral afferent nociceptive pathways
2. Central processing of nociceptive information
3. Mechanisms of action of drugs used for the treatment of neuropathic
pain.
4. Biopsychosocial model of pain
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Clinical Sciences
A. Rheumatic Diseases
For each disease, understand the epidemiology, genetics, natural history,
clinical expression including clinical subtypes, pathology, and disease
pathogenesis.
1. Rheumatoid Arthritis.
2. Seronegative spondyloarthritidies: ankylosing spondylitis, reactive
arthritis, psoriatic arthritis, inflammatory bowel disease-associated
arthritis, arthritis associated with acne and other skin diseases,
SAPHO syndrome, and undifferentiated spondyloarthritis.
3. Lupus erythematosus: systemic, discoid, and drug-related;
antiphospholipid antibody syndrome, including primary APLS
4. Scleroderma: diffuse and limited systemic sclerosis, localized
syndromes, chemical/drug-related
5. Other systemic connective tissue diseases: eosinophilic fasciitis,
eosinophila-myalgia syndrome, Sjögren’s syndrome, polymyositis and
dermatomyositis, relapsing polychondritis, relapsing panniculitis,
erythema nodosum, adult-onset Still’s disease, overlap syndromes
including mixed connective tissue disease, undifferentiated connective
tissue disease
6. Vasculitides: polyarteritis nodosa, Wegener’s granulomatosis and other
ANCA-associated diseases, allergic granulomatosis of Churg-Strauss,
temporal arteritis/polymyalgia rheumatica, Takayasu’s arteritis,
systemic necrotizing vasculitis overlaps, Behcet’s disease,
hypersensitivity and small vessel angiitis, cryoglobulinemia, Cogan’s
syndrome
7. Infectious and reactive arthritides
a. Infectious arthritides: bacterial (nongonococcal and
gonococcal), mycobacterial, spirochetal (syphilis, Lyme), viral
(HIV, hepatitis B, parvovirus, other), fungal, parasitic
b. Whipple’s disease
c. Reactive arthritides: acute rheumatic fever, arthritis associated
with subacute bacterial endocarditis, intestinal bypass arthritis,
post-dysenteric arthritides, postimmunization arthritis, other
colitic-associated arthropathies
8. Metabolic, endocrine, and hematologic disease associated rheumatic
disorders
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a. Crystal-associated diseases: monosodium urate monohydrate
(gout), calcium pyrophosphate dihydrate deposition disease,
basic calcium phosphate (hydroxyapatite), calcium oxalate
b. Endocrine-associated diseases: rheumatic syndromes
associated with diabetes mellitus, acromegaly,
hyperparathyroidism, hypoparathyroidism, hyperthyroidism,
hypothyroidism, Cushing’s disease
c. Hematologic-associated diseases: rheumatic syndromes
associated with hemophilia, hemoglobinopathies,
angioimmunoblastic lymphadenopathy, multiple myeloma
9. Bone and cartilage disorders
a. Osteoarthritis - primary and secondary osteoarthritis,
chondromalacia patellae
b. Metabolic bone disease: osteoporosis, osteomalacia, bone
disease related to renal disease
c. Paget’s disease of bone
d. Avascular necrosis of bone: idiopathic, secondary causes,
osteochondritis dissecans
e. Others: transient osteoporosis, hypertrophic osteoarthropathy,
diffuse idiopathic skeletal hyperostosis, insufficiency fractures
10. Hereditary, congenital, and inborn errors of metabolism associated
with rheumatic syndromes
a. Disorders of connective tissue: Marfan’s syndrome,
osteogenesis imperfecta, Ehlers-Danlos syndromes,
pseudoxanthoma elasticum, hypermobility syndrome, others
b. Mucopolysaccharidoses
c. Osteochondrodysplasias: multiple epiphyseal dysplasia,
spondylepiphyseal dysplasia
d. Inborn errors of metabolism affecting connective tissue:
homocystinuria, ochronosis
e. Storage disorders: Gaucher’s disease, Fabry’s disease,
Farber’s lipogranulomatosis
f. Immunodeficiency: IgA deficiency, complement component
deficiency, SCID and ADA deficiency, PNP deficiency, others
g. Autoinflammatory syndromes including familial Mediterranean
fever, Muckle-Wells Syndrome, tumor necrosis factor receptor-
associated periodic syndromes (TRAPS).
h. Others: hemachromatosis, hyperlipidemic arthropathy, myositis
ossificans progressiva, Wilson’s disease, others
11. Nonarticular and regional musculoskeletal disorders
a. Fibromyalgia
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b. Myofascial pain syndromes
c. Axial syndromes: low back pain, spinal stenosis, intervertebral
disc disease and radiculopathies, cervical pain syndromes,
coccydynia, osteitis condensans ilii, osteitis pubis,
spondylolisthesis/spondyolysis, discitis
d. Regional musculoskeletal disorders: in addition to bursitis,
tendinitis, or enthesitis occurring around each joint, the fellow
should be familiar with other disorders occurring at each specific
joint site (e.g., shoulder-rotator cuff tear, adhesive capsulitis,
impingement syndrome; wrist ganglions; trigger fingers and
Dupuytren’s contractures; knee synovial plicaes, internal
derangements, cysts; hallux rigidus, heel pain, and
metatarsalgia; TMJ syndromes; costochondritis.
e. Biomechanical/anatomic abnormalities associated with regional
pain syndromes: scoliosis and kyphosis, leg length discrepancy,
foot deformities
f. Overuse rheumatic syndromes: occupational, sports,
recreational, performing artists
g. Sports medicine: injuries, strains, sprains, nutrition, female
athlete, medication issues
h. Entrapment neuropathies: thoracic outlet syndrome, upper
extremity entrapments, lower extremity entrapments
i. Other: reflex sympathetic dystrophy, erythromelalgia
12. Neoplasms and tumor-like lesions
a. Benign
(1) Joints: loose bodies, fatty and vascular lesions, synovial
osteochondromatosis, pigmented villonodular synovitis,
ganglions
(2) Tendon sheaths: fibroma, giant cell tumor, nodular
tenosynovitis
(3) Bone: osteoid osteoma, others
b. Malignant
(1) Primary: synovial sarcoma, others
(2) Secondary: leukemia, myeloma, metastatic malignant
tumors
(3) Malignancy-associated rheumatic syndromes:
carcinomatous polyarthritis, palmoplantar fasciitis,
Sweet’s syndrome
13.Muscle diseases
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a. Inflammatory: polymyositis, dermatomyositis, inclusion body
myositis
b. Metabolic
(1) Primary: glycogen storage diseases, lipid metabolic
disorders, myoadenylate deaminase deficiency,
mitochondrial myopathies
(2) Secondary: nutritional, toxic, endocrine disorders,
electrolyte disorders, drug-induced
c. Muscular dystrophies
d. Myasthenia gravis
14.Miscellaneous rheumatic disorders
a. Amyloidosis: primary, secondary, hereditary
b. Raynaud’s disease
c. Charcot joint
d. Remitting seronegative symmetrical synovitis with pitting edema
e. Multicentric reticulohistiocytosis
f. Plant thorn synovitis
g. Intermittent arthritides: palindromic rheumatism, intermittent
hydrarthrosis
h. Arthritic and rheumatic syndromes associated with: sarcoidosis,
scurvy, pancreatic disease, chronic active hepatitis, primary
biliary cirrhosis, drugs, and environmental agents
i. Rheumatic disease in the geriatric population
j. Rheumatic disease in the pregnant patient
k. Rheumatic syndromes in dialysis patients
B. Pediatric rheumatic diseases:
Some rheumatic diseases are similar in pathogenesis, presentation, clinical
course, and treatment in both adults and children. These diseases (such as
systemic lupus, scleroderma syndromes, the systemic vasculitides, and
enteropathic arthritides) are not specifically addressed in this section. Other
diseases or specific aspects of management that are unique or more
prevalent in children are included in this outline of knowledge content. A
supplementary section, providing more detailed information and a reading list,
is provided in Appendix E.
1. Diagnose the rheumatic diseases that occur primarily in children, and
know how they differ from the same, or similar, disease in adults.
a. Systemic juvenile rheumatoid arthritis (Still’s Disease)
b. Pauciarticular juvenile rheumatoid arthritis
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c. Polyarticular juvenile rheumatoid arthritis
d. Juvenile spondyloarthropathy
e. Juvenile dermatomyositis
f. Kawasaki Disease
g. Henoch-Schonlein Purpura
h. Acute rheumatic fever
i. Neonatal lupus syndrome
j. CINCA (NOMID)
k. PFAPA syndrome (periodic fever, aphthous stomatitis,
pharyngitis, and adenitis)
2. Know the major sequelae or life-threatening complications of rheumatic
diseases that occur primarily in children:
a. Systemic onset JRA
(1) Macrophage activation syndrome
(2) Cardiac tamponade
b. Pauciarticular JRA
(1) Chronic uveitis
c. Juvenile dermatomyositis
(1) GI vasculitis
(2) Calcinosis
d. Kawasaki Disease
(1) Aneurysms of coronary and other arteries
e. Henoch-Schonlein Purpura
(1) GI- intussusception, intestinal infarction
(2) Renal - chronic nephritis
f. Neonatal lupus syndrome
(1) Congenital heart block
(2) Thrombocytopenia
3. Know the appropriate treatments of the above childhood rheumatic
disorders, and complications of treatment.
4. Recognize non-rheumatic disorders in children that can mimic
rheumatic diseases:
a. Infectious or post-infectious syndromes
(1) Septic arthritis and osteomyelitis
(2) Transient synovitis of the hip
12
(3) Post-infectious arthritis and arthralgia
(4) Post-viral myositis
b. Orthopedic conditions
(1) Legg-Calve-Perthes Disease and other avascular
necrosis syndromes
(2) Slipped capital femoral epiphysis
(3) Spondylolysis and spondylolisthesis
(4) Patellofemoral syndrome
c. Non-rheumatic pain
(1) Benign limb pains of childhood (“growing pains”)
(2) Benign hypermobility syndrome
(3) Pain amplification syndromes including reflex
sympathetic dystrophy
d. Neoplasms
(1) Leukemia
(2) Lymphoma
(3) Primary bone tumors (especially osteosarcoma and
Ewing’s sarcoma)
(4) Tumors metastatic to bone (especially neuroblastoma)
e. Bone and cartilage dysplasias, and inherited disorders of
metabolism
5. Know aspects of rheumatic disease and treatments specific to children:
a. Disease effects on growth
(1) Accelerated or decelerated growth of limbs or digits
affected by arthritis
(2) Altered growth of mandible in TMJ arthritis
(3) Short stature and failure to thrive
b. Regular surveillance for uveitis in JRA
c. Drugs
(1) FDA approved drugs for childhood rheumatic diseases
(2) Drug metabolism and dosing different from adults
d. Child-specific side effects of chronic corticosteroid treatment
(1) Growth retardation
(2) Delay of puberty
e. Physical and occupational therapy
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(1) Exercises
(2) Splinting
f. Psychosocial and developmental issues
(1) Peer and sibling interaction
(2) Family adjustment
(3) School accommodations for disability
(4) School and recreational activities
(5) Transition to adulthood
C. Therapeutic modalities and strategies
1. Pharmacology: for each medication, understand the dosing,
pharmacokinetics, metabolism, mechanisms of action, side effects,
drug interactions, compliance issues, costs, and use in specific patient
populations, such as renal insufficiency and including fertile, lactating,
and pregnant women.
a. Nonsteroidal anti-inflammatory drugs
b. Glucocorticoids: topical, intraarticular, systemic
c. Systemic antirheumatic drugs: antimalarials, sulfasalazine, gold
compounds, methotrexate, D-penicillamine
d. Cytotoxic drugs: azathioprine, cyclophosphamide, chlorambucil
e. Immunomodulatory drugs: cyclosporine, mycophenolate mofetil,
tacrolimus
f. Biologic agents
g. Hypouricemic drugs: allopurinol, sulfinpyrazone, probenecid
h. Antibiotic therapy for septic joints
i. Narcotic and non-narcotic analgesics
j. Tricyclics and other agents used for pain modulation
k. Anticholinergics and non pharmacologic agents used for the
treatment of sicca symptoms
l. Others: apheresis, ionizing radiation
2. Rehabilitation and disability issues
a. Methods of rehabilitation: for each method, understand
principles, mechanism of action, indications, precautions and
contraindications, potential side effects, and costs.
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b. Importance of multidisciplinary approaches to rehabilitation and
pain control. Appropriate use of and referral/prescription to
rehabilitation specialists and pain clinics.
c. Exercise: range of motion, strengthening, conditioning, and
stretching
(1) Rest and splinting
(2) Modalities and hydrotherapy: ultrasound, TENS
iontophoresis, spa therapy
(3) Joint protection and energy conservation techniques
(4) Adaptive equipment and assistive devices
(5) Job site/home evaluation and adaptation
(6) Footwear and orthotics
(7) Acupuncture and other alternative modalities
(8) Nutritional issues
d. Demonstrate understanding of specific rehabilitative
techniques/modalities and what modification of these
techniques are needed depending on the patient’s disease (e.g.
osteoarthritis, myositis, etc.), location of symptoms (e.g. back,
shoulder, etc) and other related issues.
e. Psychosocial aspects of disability: understand the impact that
the following factors have on the overall therapy of a patient with
rheumatic disease and demonstrate knowledge of what can be
done to assist a patient in these areas.
(1) Psychological and emotional factors including sexuality
(2) Economic and vocational issues: vocational
rehabilitation, costs of therapy and monitoring
(3) Disability determination: impairment vs disability,
evaluation and measurement, social security disability,
workmen’s compensation, other
(4) Compliance issues
3. Surgical management
a. For each procedure, the fellow should possess a working
knowledge of indications, preoperative evaluation and
medication adjustments, contraindications, complications,
postoperative management, and expected outcome.
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(1) Bone biopsy
(2) Arthroscopy
(3) Synovectomy of tendons and joints
(4) Entrapment neuropathy release
(5) Osteotomies: hip, knee
(6) Arthrodesis: wrist, other
(7) Spine surgery: radiculopathy, stenosis, and instability
(8) Reconstructive surgery of hand and foot
(9) Total joint replacement: hip, knee, shoulder, other
(10) Specific surgical management problems:
i
Rheumatoid arthritis patient
ii Infected joint: arthrosopy vs. arthrotomy
iii Infected prosthetic joint
iv Ankylosing spondylitis patient
v Pediatric rheumatic disease patient
vi Prevention and treatment of deep venous
thrombosis
vii Perioperative antirheumatic medication
management
4. Complementary and alternative medical practices: diet, nutritional
supplements, antimicrobials, acupuncture, chiropractic, topicals,
homeopathic remedies, venoms, others
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Diagnostic Testing
A. Laboratory tests: for each test, understand the biologic rationale, methods for
performing, and utility/limitations of specific laboratory tests including but
limited to:
1. Erythrocyte sedimentation rate, C-reactive protein, and other acute
phase reactants
2. Rheumatoid factors, cryoglobulins, and circulating immune complexes
3. Anti-cyclic citrullinated peptide antibodies
4. Antinuclear antibodies and subtype specificities including anti-dsDNA,
anti-Smith, anti-U1 RNP, anti-centromere antibodies, and anti-histone
antibodies; and LE cell preparation
5. Antiribosomal P, anti-topoisomerase 1, and anti-synthase antibodies
including anti-Jo-1
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6. Anti-neutrophil cytoplasmic antibodies including specificities for
neutrophil granule constituents [anti-PR3, anti-myeloperoxidase]
7. Antiphospholipid antibodies including RPR, lupus anticoagulant,
anticardiolipin and beta-2-glycoprotein I antibodies
8. Antibodies to formed blood elements including direct and indirect
Coombs testing, anti-platelet antibodies, anti-granulocyte antibodies
9. Assays for complement activity (CH50) and components of the
complement cascade
10.Serum immunoglobulin levels, Serum protein electropheresis and
immunofixation electropheresis
11.HLA typing
12.ASO and other streptococcal antibody tests
13.Serologic and PCR tests for Lyme disease, HIV, Hepatitis B, Hepatitis
C, parvovirus and other infectious agents
14.Serum and urine measurements for uric acid
15.Iron studies including ferritin
16.Flow cytometry studies for analysis of lymphocyte subsets and function
17.Specific genetic testing
B. Diagnostic imaging techniques: understand the basic underlying principles
and technical considerations in the use of plain radiographs, computed
tomography, magnetic resonance imaging, ultrasonography and radionuclide
scanning of bones, joints, and periarticular and vascular structures.
C. Synovial fluid analysis: cell count and differential, crystal identification,
viscosity, protein, glucose, and other special stains/analyses
D. Test-performance characteristics: principles of sensitivity, specificity, and
predictive value
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Research Principles
A. Principles and methods of epidemiological research
1. Definitions of incidence and prevalence
2. Basic biostatistics: including major methods of comparative analysis,
types of error, likelihood ratios
3. Methods of health services research
b. Measurement of health and functional status (HAQ, SF36, etc).
c. Quality of life measurements/assessments
d. Components of cost analysis (direct costs, QALY, etc.)
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B. Principles of clinical research
1. Major study designs and the limitations and biases associated with
each
2. Diagnostic criteria and assessment of disease activity
a. Objective assessments, e.g. tender joint count
b. Composite indices (ACR composite, DAS, WOMAC, etc.)
c. Damage and functional indices (e.g. HAQ)
3. Clinical trials
a. Major design types
b. Definitions and uses of clinical trial Phases
c. Roles of principal investigator, sponsors, study coordinators,
monitors, IRB.
C. Evidence-based medicine: Data analysis, biostatistics, meta-analysis and
medical informatics
D. Laboratory techniques
1. Serologic: ELISA, RIA, RID, nephelometry, immunoblots, protein
electrophoresis, circulating immune complex assays.
2. Cellular: lymphocyte proliferation, flow cytometry.
3. Histochemistry and immunofluorescence of biopsied tissues.
4. Molecular: Northern, Southern and Western blot analysis polymerase
chain reaction; gene sequencing; genomics techniques (SNP, RFLP
analysis, microarray techniques)
5. Hybridoma and monoclonal antibody production
6. Transgenic and gene knock-out animals
E. Bioethics of clinical and basic research
F. Critical literature review
Methods for Acquisition
The fund of knowledge obtained through this curriculum should serve as the foundation
for understanding the pathogenesis, diagnosis, and treatment of the rheumatic
diseases. The methods and resources for acquiring the body of medical knowledge
include, but are not limited to:
?
Didactic teaching - conferences, lectures, or discussions
?
Independent reading - recommended textbooks, journal articles and internet
based research and study
?
Clinical laboratory experience
18
?
Research experience
?
Attendance at regional and national meetings and conferences
Performance Markers
The fellow is expected to know and apply basic and clinical science relevant to
rheumatology and should demonstrate an analytic and investigatory approach to clinical
situations.
Basic Science – The fellow should be able to demonstrate understanding of
anatomy, basic immunology, cell biology and metabolism pertaining to the
rheumatic diseases in both didactic and clinical settings.
Clinical Science – The fellow demonstrates understanding of pathogenesis,
epidemiology, clinical expression, treatments and prognosis of the full range of
rheumatic and musculoskeletal disease in both didactic and clinical settings.
Diagnostic Testing – The fellow displays an understanding of the biological and
physical and basis of the range of diagnostic testing in rheumatology and the
clinical test characteristics of these procedures.
Research Principles: The fellow should be able to:
A. Demonstrate an understanding of the essential components of clinical study
design, patient assessment and data analysis.
B. Exhibit familiarity with the common experimental approaches used in
laboratory, clinical and epidemiology research.
C. Exhibit familiarity with the principles of the ethical conduct of research and the
ability to apply these principles in the conduct of their own research during
fellowship.
Evaluation Methods
?
Faculty performance rating – with regard to medical knowledge
?
Evaluation committee
?
Formal oral or written exam
?
Mentor evaluation of trainee's research performance
Suggested Reading List and Web Links
1. Major textbooks of rheumatology
2. Clinical Epidemiology. A Basic Science of Clinical Medicine. Sackett DL, Haynes
RB, Guyatt GH and Tugwell P, Little, Brown, New York, 2
nd
ed. 1991.
3. ACR Suggested Reading List for Rheumatology Fellows
http://www.rheumatology.org/educ/training/readinglist/index.asp?aud=mem
4. Up-To-Date
http://www.utdol.com
19
II.
Patient Care
The ability to provide quality patient care is the ultimate goal of clinical training in
rheumatology. The fellowship program must require its residents to obtain competence
in patient care to the level expected of a new practitioner. Programs must define the
specific knowledge, skills, behaviors, and attitudes required, and provide educational
experiences as needed in order for their residents to demonstrate quality patient care.
Definition
Patient Care that is compassionate, appropriate, and effective for the treatment of
disease and the promotion of health.
Essential Components
The essence of being a rheumatologist is the ability to use information derived about a
patient (history, physical examination, laboratory and imaging studies) along with
medical knowledge to orderly synthesize a differential diagnosis, plan of further
evaluation and comprehensive management for the patient with a rheumatologic
problem. This may broadly be categorized under four components:
?
Information Gathering
A. Obtaining the history
B. Performing a careful physical examination
C. Obtaining appropriate tests, including laboratory tests, imaging studies, and
others
?
Synthesis of Treatment Plan
Informed medical decision making based on up-to-date scientific information and
clinical judgement that also accounts for patient preferences and circumstances.
?
Implementation of Treatment
A. Prescribing medications and rehabilitation
B. Patient education and counseling
C. Preventive medicine and proactive care
D. Therapeutic aspiration and injection
E. Utilization of allied health care professionals, including those from other
disciplines
20
?
Reassessment and patient follow up
A. Assessment of treatment response
B. Recognition of treatment related adverse events
Methods for Acquisition
Learning the essentials of patient care is primarily acquired by caring for patients in the
outpatient clinic as well as the inpatient (hospitalized) settings. These supervised
experiences are the focus of clinical training where the trainee observes skilled clinician
role models, and participates with the patient in the management of their rheumatologic
problem. Situations in which facets of patient care are taught and learned include:
?
Didactic teaching - conferences, lectures, or discussions
?
Clinical experience in a supervised, mentored clinical setting
?
Interactive case-based discussions
?
Independent reading - recommended textbooks, journal articles and internet
based research and study
?
Attendance at regional and national clinical meetings and conferences
?
Preparation of patient care portfolios
Performance Markers
?
Information Gathering - The fellow should be able to:
A. Understand principles and demonstrate competency in obtaining a clinical
history, relevant review of systems, and assessing functional status of
patients with rheumatic disease symptoms.
B. Understand principles and demonstrate competency in performing and
interpreting the examination of the structure and function of all axial and
peripheral joints, periarticular structures, peripheral nerves and muscles.
Additionally, the fellow should be able to identify extraarticular findings that
are associated with specific rheumatic diseases.
C. Understand the indications for and costs of ordering laboratory tests,
procedures to establish a diagnosis of rheumatologic disease and of different
therapies used in the management of these diseases.
D. Understand the principles and interpretation of results of synovial fluid
analysis and become proficient in the examination and interpretation of
synovial fluid under conventional and polarized light microscopy from patients
with a variety of rheumatic diseases.
E. Demonstrate understanding and competency in the assessment and
interpretation of:
21
1. Radiographs of normal and diseased joints, bones, periarticular
structures and prosthetic joints
2. Bone densitometry
F. Apply the principles of clinical epidemiology to day-to-day clinical decision
making, demonstrating understanding and competency in the indications for
and the interpretation of results from laboratory tests and procedures to
establish a diagnosis of a rheumatologic disease, including:
1. Arthrography, ultrasonography, computed tomography, magnetic
resonance imaging of joints, bones and periarticular structures
2. Radionuclide scans of bones and joints
3. Arteriograms (conventional and MRI/MRA) for patients with suspected
or confirmed vasculitis
4. Computed tomography of lungs and paranasal sinuses
5. Magnetic resonance imaging of the central nervous system (brain and
spinal cord)
6. Electromyograms and nerve conduction studies
7. Biopsy specimens including histochemistry and immunofluorescence
of tissues relevant to the diagnosis of rheumatic diseases: skin,
synovium, muscle, nerve, bone (e.g. metabolic bone disease), minor
salivary gland, artery, kidney and lung
8. Specific laboratory tests (including, but not limited to) erythrocyte
sedimentation rate, C-reactive protein, other acute phase response
proteins (e.g. ferritin), rheumatoid factor, anti-cyclical citrillunated
peptides, antinuclear antibodies, anti dsDNA, anti SSA (anti-Ro), anti
SSB (anti-La), anti-U1RNP, anti-Sm, anti-topoisomerase I (Scl-70),
anti-Jo-1, anti-PM-Scl, antihistone antibodies, antineutrophil
cytoplasmic antibodies (including anti-myeloperoxidase and anti-
proteinase-3), cryoglobulins, complement component levels, CH50,
serum protein electrophoresis, serum immunoglobulin levels, LE
preparation, RPR, lupus anticoagulant assays, anticardiolipin and other
antiphospholipid antibodies, HLA typing (e.g. HLA-B27), ASO and
other streptococcal antibody tests, Lyme serologies, serum and urine
uric acid levels, circulating immune complexes, lymphocyte subset and
function data, anticellular antibodies (e.g. Coombs’ test, neutrophil
antibodies and anti-platelet antibodies)
9. Arthroscopy
10.Schirmer’s and rose Bengal tests; parotid scans and salivary flow
studies
22
?
Synthesis of Treatment Plan - The fellow should be able to:
A. Demonstrate the ability to construct a differential diagnosis in patients
presenting with signs and symptoms related to rheumatologic diseases and to
outline further testing necessary to establish the correct diagnosis.
B. Demonstrate the ability to construct and implement an appropriate treatment
plan for the care of a patient with a rheumatologic problem integrating the
prescribing of medications (oral, injectable or infused), counseling,
rehabilitative medicine, and, when necessary, surgical or other consultation.
The fellow should be able to explain the rationale and the risks/benefits for
the treatment plan.
?
Implementation of Treatment - The fellow should be able to:
A. Demonstrate a working knowledge of clinical pharmacology: for each
medication, understand the dosing, pharmacokinetics, metabolism,
mechanisms of action, side effects, drug interactions, compliance issues,
costs, and use in patients including fertile, lactating, and pregnant women.
1. Nonsteroidal anti-inflammatory drugs and adequate gastroprotection
2. Glucocorticoids: topical, intraarticular, systemic
3. Disease modifying antirheumatic drugs:
a. historical agents such as gold compounds and penicillamine
b. oral agents: methotrexate, antimalarials, sulfasalazine,
leflunomide, tetracyclines, auranofin
c. parenteral biological response modifiers including inhibitors of
TNF, IL-1 and other cytokines and immune based therapies
such as CTLA4Ig, anti-CD20
4. Cytotoxic drugs: azathioprine, cyclophosphamide, chlorambucil,
5. Immunomodulators: cyclosporine, FK-506, mycophenolate mofetil
6. Hypouricemic drugs: allopurinol, sulfinpyrazone, probenecid
7. Antibiotic therapy for septic arthritis, Lyme disease
B. Experimental therapies: plasmapheresis, intravenous immunoglobulin,
myeloablative therapy and immune reconstitution including stem cell
transplantation
C. Understand the indications for and demonstrate competence in
arthrocentesis. The fellow should understand the anatomy, precautions
(including OSHA requirements) and potential sequelae of arthrocentesis and
demonstrate competency in obtaining synovial fluid from diarthrodial joints,
bursae and tenosynovial structures with adequate informed consent.
D. Understand pain assessment and pain management:
23
1. Methods of pain assessment including visual analog scale scores, pain
questionnaires
2. Non-pharmacological modalities of pain management including
exercise, cognitive behavioral therapy
3. Pharmacological therapy including:
a. Immunosuppressive and anti-inflammatory management of
underlying rheumatic disorder.
b. Analgesic agents including acetaminophen, nonsteroidal anti-
inflammatory agents and narcotic analgesics.
c. Antidepressants
d. Investigational uses of approved drugs such as gabapentin
E. Understand changes required in patient management should the
rheumatology patient become pregnant; this should include pre-pregnancy
counseling about ramifications of becoming pregnant on the disease process,
the use of medications before and during pregnancy and in the postpartum
period.
F. Demonstrate the ability to identify physical impairment; relate the impairment
to the observed functional deficits; prescribe appropriate rehabilitation
(physical therapy, occupational therapy) to achieve goals to improve the
defined impairment.
G. Understand indications for surgical and orthopedic consultation in acute and
chronic rheumatic diseases.
H. Pre- and Post-operative Management of the Surgical Patient:
1. Understand indications for surgical and orthopedic consultation in
acute and chronic rheumatic diseases.
2. Understand perioperative evaluation, appropriate referral and
medication adjustments.
3. Rehabilitation of the rheumatic disease patient after a surgical or
orthopedic procedure, as well as aspects of postoperative medical
management pertaining to the rheumatologic condition.
I. Understand complementary and unconventional medical practices: diet,
nutritional supplements, antimicrobials, acupuncture, topical therapeutic
agents, homeopathic remedies, venoms, and others.
?
Reassessment and patient follow up - The fellow should be able to
demonstrate the ability to reassess the patient over time, including recognition of
treatment related adverse events, and alter the treatment plan accordingly.
Evaluation Methods
?
Faculty performance rating – with regard to patient care
24
?
Evaluation committee
?
Chart review – for patient care, drug prescribing, or outcomes
?
Clinical evaluation exercise (mini-CEX)
?
Objective structured clinical examination (OSCE)
?
360 evaluations
?
Portfolio review
Suggested Reading List and Web Links
1. Bingham JW, Quinn DC, Richardson MG, Miles PV, Gabbe SG, Using a healthcare
matrix to assess patient care in terms of aims for improvement and core
competencies, J Qual Patient Safety 2005;31:98-105.
2. The American Board of Internal Medicine has published a series of trainee
evaluation tools including guidelines and forms for a Mini-CEX and several
professional associate rating forms that can be used to rate fellow performance.
https://www.abim.org/resources/publications/index.shtm
and
https://www.abim.org/resources/publications/SSGENERI.pdf
25
III.
Practice-based Learning and Improvement
The practice of rheumatology entails the assessment and treatment of patients with
clinical disorders that are often complex with regard to the variable organ systems
involved, variations in musculoskeletal and immune system biology, and impact upon
patient lifestyle and livelihood.
This complexity and the rapid advances in
understanding of both disease pathogenesis and treatment of the rheumatic diseases
demands that the rheumatologist continually evaluate and improve the quality of their
care in the context of their own clinical practice. The development of skills in self-
directed, reflective learning and practice improvement will facilitate the delivery of state-
of-the-art, evidence-based patient care that maximizes the likelihood for successful
clinical outcomes.
Definition
Practice-based learning and improvement involves the evaluation of care provided to
both individual patients as well as to groups of patients in a given practice, the appraisal
and assimilation of scientific evidence relevant to clinical problems encountered,
evaluations of the care provided in the context of this evidence, and effecting
improvements in patient care based upon these evaluations.
Essential Components
In addition to structured learning of the basic components of medical knowledge and
patient care, the rheumatologist must evaluate their knowledge base and care delivery
on an ongoing basis with the goal of continually improving that care. This process
includes the following components:
?
Independent learning
The ability to access and critically appraise appropriate information systems and
sources to improve understanding of underlying pathology, assess the accuracy
of diagnoses, and gauge appropriateness of therapeutic interventions for the
patient population they encounter.
?
Self-evaluation of performance
The effective rheumatologist must engage in ongoing self-assessment activities.
This includes the ability to continuously self-evaluate learning needs and to
monitor practice behaviors and outcomes to ascertain whether clinical decisions
and therapeutic interventions are effective, and adhere to accepted standards of
care.
26
?
Incorporation of feedback into improvement of clinical activity
The ability to appropriately interpret results of clinical outcome studies, practice
data, quality improvement measures, and faculty/peer feedback and evaluations
and apply them to patient care and practice behavior.
Methods for Acquisition
?
Clinical experience in a supervised, mentored clinical setting
?
Independent reading - recommended textbooks, journal articles and internet
based research and study
?
Faculty-facilitated group discussions and tutorials
?
Faculty role modeling
?
Interactive case-based discussions
?
Systematic chart review of their own patients
?
Preparation of patient care portfolios
?
Presentations to peers and lay audiences
?
Participation in individual or group quality improvement projects
Performance Markers
?
Independent learning - the fellow should be able to:
A. Utilize information technology to search, retrieve, and interpret medical
information relevant to the care of patients with rheumatic disease from
sources such as:
1. Peer-reviewed clinical journal articles
2. Clinical case reports
3. Internet-based resources such as Up-To-Date
4. Clinical performance guidelines published by the ACR and other
groups
5. Conversations with colleagues and peers
6. CME activities including attendance at national and regional meetings
B. Critically evaluate and interpret the medical literature using knowledge of
clinical study methodology, statistics and methods of health services
research.
C. Apply learned concepts and conclusions from studies and case reports to the
care of individual patients.
27
D. Facilitate the learning of students and other health care professionals.
?
Self-evaluation of performance - the fellow should be able to use a systematic
approach, such as a chart review, to analyze own practice and identify learning
or practice improvement needs.
?
Incorporation of feedback into improvement of clinical activity - the fellow
should be able to:
A. Demonstrate the ability to improve own practice based upon specific
feedback and learned concepts.
B. Assess the impact of practice improvements on the care of own patients.
C. Implement global quality improvement measures in own practice.
Evaluation Methods
?
Faculty performance rating - with regard to demonstration of reflective
learning in clinical venues.
?
Evaluation committee - review of trainee presentations, portfolio-based
presentations, and journal article reviews related to practice-based learning
and improvement.
?
Portfolio review - with respect to residents' narratives of critical incidences or
other experiences (usually accompanied by reflection on the event), and
practice improvement.
Suggested Reading List and Web Links
1. Moore DE, Pennington FC, Practice-based learning and improvement, J Cont Educ
Health Prof, 2003;23:S73-80.
2. Epstein RM, Mindful practice, JAMA, 1999;282:833-9.
3. “Advancing Education in Practice-Based Learning and Improvement.” An
educational resource developed by the ACGME to aid program directors in teaching
and assessing PBLI located at
http://www.acgme.org/outcome/implement/complete_PBLIBooklet.pdf
4. A comprehensive list of professionalism references is also available from the
ACGME at
http://www.acgme.org/outcome/comp/refs_PBLI805.pdf
28
IV. Systems-based Practice
The increasing complexity and diversity of health care delivery systems presents both
challenges and opportunities for the practice of rheumatology. Knowledge of the nature
and variety of the external and internal systems that can impact clinical practice and the
effective utilization of that knowledge to positively impact patient care is an essential
skill. Trainee competence in such systems-based practice “…includes an understanding
of how their own practices affect others, and knowing how to partner with others to
improve health care”
1
.
The knowledge base of systems-based practice comprises the advantages and
disadvantages of different health care systems that impact on patients with rheumatic
disease. Some of these include the academic system in which rheumatology fellows
are training, the various private and public health care delivery systems, the
governmental agencies and programs that regulate these systems, the volunteer,
private and governmental agencies that are available to educate and assist patients, the
bureaucracy faced by disabled patients negotiating these systems and the social and
economic burden of chronic rheumatic diseases.
The goal of the systems-based
practice curriculum is to enhance the ability of rheumatology trainees to positively
influence patient care by effectively utilizing these internal and external resources, to
serve as effective advocates for their patients, and to provide cost-effective patient care.
In some cases this may also mean identifying and organizing change in the local
systematic problems that lead to inferior patient care.
These two major aspects of systems-based practice (systems knowledge acquisition
and systems utilization) are already incorporated in rheumatology training programs.
The purpose of the systems-based practice curriculum is to clarify the components of
systems-based practice, describe how and where the knowledge is acquired, set
benchmarks of performance expected of the trainees, and describe the tools used to
measure that performance.
Definition
Systems-based practice reflects an understanding of and responsiveness to the larger
context and system of health care, as well as the ability to call effectively on other
resources in the system to provide optimal health care.
Essential Components
?
Systems: a concept of “systems thinking” in health care delivery
This includes an understanding of the limitations and opportunities of various
types of rheumatology practices and delivery systems, practice management
strategies, managed care and health insurance issues. It also comprises an
29
ongoing analysis of the strengths and weaknesses of the local academic system,
in both the inpatient and outpatient settings, and its impact on the health care
delivery to rheumatic patients. In particular, efforts should be made to identify
potentially correctable systematic weaknesses and medical errors due to
systems failure and to develop strategies to rectify the problems (i.e. Quality
Improvement projects)
?
Partners in health care delivery: the various providers and resources available
to deliver optimal care.
The principal partners in delivering health care to rheumatic patients include
providers such as nurses, physiatrists, orthopedists and allied health
professionals available within the local healthcare system. Partners also include
outside volunteer agencies, both locally and nationally, such as the American
College of Rheumatology, the Arthritis Foundation, the disease-specific
foundations (Lupus, Scleroderma, Ankylosing Spondylitis, etc), the National
Institute of Arthritis, Musculoskeletal and Skin Diseases (NIAMS) and
pharmaceutical companies that have specific patient-related initiatives. Other
agencies that impact on the practice of rheumatology include the American
Medical Association (AMA), the Food and Drug Administration (FDA) and the
Center for Medicare and Medicaid Services (CMS).
?
Advocacy for the patient: the importance, opportunities and limits of patient
advocacy
This advocacy might consist of assisting patients with applications for Medicaid
disability, completing preauthorization documents for the use of certain
medications and appealing to HMOs with respect to denial of certain treatments,
benefits and claims.
?
Cost-effective health care: the principles of cost allocation and resource
management within the external (state, national) and local systems
This includes a knowledge of the cost and availability of certain drugs (and
unavailability of others) on the trainee’s hospital formulary, the mechanisms by
which compensation (by CMS and other carriers) is dependent upon the delivery
of various levels of service to patients and the methods in place for Quality
Review of inpatient and outpatient practice patterns. The utilization of evidence-
based cost-conscious strategies for the diagnosis and treatment of patients with
rheumatic diseases is paramount.
Methods for Acquisition
?
Clinical experience in a supervised, mentored clinical setting
30
?
Didactic teaching - conferences, lectures, or discussions that highlight
particular systems-based practice issues, including multidisciplinary
conferences related to individual patients
?
Faculty-facilitated group discussions and tutorials used to identify systematic
problems in patient care delivery
?
Independent reading specifically related to systems-based practice issues
?
Preparation of patient care portfolios. Appropriate portfolio entries might
include:
o
Documentation of instances of leadership in the multidisciplinary
management of complicated patients, of utilization of outside resources
for patient care, of patient advocacy.
o
Participation in a project to modify the patient medical record system
(electronic medical record or hard copy system).
o
Participation in a program to improve triage system in ER for patients
with acute rheumatic disease.
o
Developing an outpatient system that would allow patients with acute
rheumatic complaints appointments within 24 hrs.
o
Outpatient records survey for compliance with evidence-based
diagnostic or therapeutic guidelines and development of strategies to
correct deficiencies, e.g. laboratory monitoring of patients on DMARDs,
PPD testing before TNF antagonists.
?
Participation in individual or group quality improvement projects
Performance Markers
?
Systems: The fellow should be able to:
A. Demonstrate knowledge about how different health care delivery systems
affect the management of patients with rheumatic diseases.
B. Practice management: be familiar with types of practice, equipment,
insurance, economics, personnel, ethical aspects, quality assurance, and
managed care issues relating to the practice of rheumatology.
C. Identify the strengths and weaknesses of the system in which they are
training and practicing. They should also demonstrate the ability to develop
strategies to overcome systematic problems they have identified, and/or QI
projects to improve it.
D. Be familiar with the history of rheumatology, and national organizations such
as the American College of Rheumatology, the Arthritis Foundation, and the
Association of Rheumatology Health Professionals.
E. Understand the influence on rheumatology of the American Medical
Association, Food and Drug Administration, CMS and other governmental
agencies involved in health care legislation, and peer review organizations.
31
?
Partners – The fellow should be able to utilize multiple providers and resources
as needed for optimal patient care.
A. Understand the rheumatologist’s role as well as when to consult other health
professionals (physiatrist, nurse practitioner, visiting nurse, physical therapist,
occupational therapist, podiatrist, social worker, vocational rehabilitation
counselor, psychologist, others) in the outpatient and inpatient rehabilitation
of patients with rheumatic diseases.
B. Demonstrate the ability to educate patients about outside resources which
might be of assistance to their physical, emotional and financial well being.
Examples of these external resources include the Arthritis Foundation self
help groups, Lupus Foundation support groups and pharmaceutical company
initiated financial aid programs.
?
Advocacy
A. The rheumatology fellow should demonstrate the ability to act as effective
advocates for quality care for their patients in a variety of needs, such as
dealing with insurance companies and HMO’s, for preauthorizations for
medications, filing disability claims, etc.
B. The fellow should demonstrate the ability to assist patients in dealing with
health system complexities.
?
Cost effective care
A. The fellow should know the local costs of medications they prescribe,
rheumatologic lab tests they order and commonly used diagnostic tests and
procedures.
B. The fellow should demonstrate a commitment to the practice of appropriate
evidence-based cost-conscious patient care.
Evaluation Methods
?
Faculty performance rating - with regard to demonstration of effective
systems-based performance markers.
An example would be an assessment of the trainee's performance in
assembling and leading multidisciplinary health care teams in the
management of inpatients (e.g. a complicated SLE patient) and
outpatients (e.g. a severe rheumatoid arthritis patient). This might involve
directing patient management with social work, physical and occupational
therapists,
rehabilitation medicine specialists, orthopedics,
and/or
geriatrics.
?
Patient survey - with components that specifically address advocacy issues
and cost effective health care delivery.
?
360 evaluations
32
?
Portfolio review - for documentation of systems-based practice performance
markers, including QI projects.
?
Formal written or oral exam – testing for knowledge about SBP issues
Suggested Reading List and Web Links
1. Systems-based practice: to learn about and improve the system. ACGME Bulletin,
November, 2004.
Useful bulletin with papers and abstracts on SBP and how different institutions have
attempted to teach and assess it.
2. Nolan TW, Understanding medical systems, Ann Intern Med 1998; 128: 293-298.
Describes the nature of medical systems, their problems and key principles to
improve them
3. Macones GA, Goldie SJ, Peipert JF: Cost-effective analysis: an introductory guide
for clinicians. Obstet Gynecol Surv 1999; 54:663-672.
Summarizes principles of cost-effective analysis
33
V.
Interpersonal and Communications Skills
Interpersonal and communication skills are essential for the formation of a desirable and
effective physician-patient relationship.
The complexity of most of the rheumatic
diseases, as well as the increasingly complicated treatment regimens, require a working
partnership between patient and physician, and often between physician and the
patient's family.
In addition to improved patient satisfaction, confidence and
understanding, such working partnerships promote medical compliance.
Effective
physician collegial relationships are also dependent upon these skills.
Definition
Interpersonal and communication skills that result in the effective exchange of
information and collaboration with patients, their families, and other health
professionals.
Essential Components:
?
Gathering information
Reliable and effective communication depends upon the availability of accurate
and complete information obtained from patients, their family and the complete
medical record. This requires the use of effective listening and communication
skills.
?
Understanding and incorporating patient's perspective
Such understanding impacts the ability of the physician to appreciate the
functional impact of disease and the desire and ability of the patient to be an
active partner in the physician’s treatment efforts.
?
Providing Information
Communication regarding disease causation, diagnosis and treatment is only as
effective as the ability of the recipient to understand the information. Effective
explanation therefore requires that the physician communicate in a manner that
is understandable to the listener.
?
Trust
Establishment of trust with patient and patient's family.
34
Methods of Acquisition
?
Clinical experience in a supervised, mentored clinical setting
?
Faculty role modeling
?
Independent reading
?
Faculty-facilitated group discussions and tutorials
?
Interactive case-based discussions
?
Systematic chart review of their own patients
?
Presentations to peers and lay audiences
?
Participation in quality assurance/improvement initiatives
Performance Markers
?
Gathering information - the fellow should be able to:
A. Use effective verbal, nonverbal, listening, questioning and explanatory skills
to obtain a complete and accurate history.
B. Obtain properly informed consent.
?
Understanding and incorporating patient's perspective - the fellow should be
able to:
A. Reliably and accurately communicate the patient's and their family's views
and concerns to others.
B. Interact with patients in an empathic and understandable manner.
?
Providing information - the fellow should be able to:
A. Write clear and effective consultations in the medical record and in letters to
referring physicians.
B. Work effectively with colleagues and peers as a member or leader of a health
care team.
C. Clearly explain benefits and risks of treatment.
D. Display effective teaching skills to colleagues and patients.
?
Trust - the fellow should be able to create and maintain an effective therapeutic
and ethically sound relationship with patients over time.
Evaluation Methods
?
Faculty performance rating – with respect to communication skills and
interpersonal relations
35
?
Patient survey - with components that specifically address trainee’s
interpersonal skills
?
Objective structured clinical examination (OSCE)
?
Clinical evaluation exercise (CEX)
Suggested Reading List and Web Links
1. Laine C, Davidoff F, Patient-centered medicine. A professional evolution, JAMA
1996; 275:152-6.
2. Burack JH, Irby DM, Carline JD, Root RK, Larson EB, Teaching compassion and
respect. Attending physicians' responses to problematic behaviors, J Gen Intern
Med 1999;14:49-55.
3. “Interpersonal and Communication Skills.” An educational resource developed by
the ACGME to aid program directors in teaching and assessing interpersonal and
communication skills located at
http://www.acgme.org/outcome/implement/interperComSkills.pdf
36
VI. Professionalism
Professionalism is one of the foundations of the practice of medicine and is frequently
an inherent character trait in a well-rounded physician. By virtue of their prior medical
school and internal medicine training, rheumatology fellows have already attained a
substantial level of professionalism, which can be refined during the fellowship training
period. The range of current therapies, including biologic agents, and the complexity of
many severe or life threatening rheumatic diseases that require potentially toxic
chemotherapeutic agents, place rheumatology trainees in close contact with referring
providers, subspecialty consultants, allied health care providers, and hospital and health
insurance administrators during the care of their patients. Trainees in many programs
also interact with patients from a wide range of cultural and socioeconomic
backgrounds.
In addition, fellows are increasingly targeted by the pharmaceutical
industry in an attempt to influence prescribing habits at an early phase of their careers.
A substantial level of professionalism is thus required to maintain the balance required
be an effective rheumatologist.
Definition
Professionalism is manifested through a commitment to carrying out professional
responsibilities, adherence to ethical principles, and sensitivity to patients of diverse
backgrounds.
Essential Components
?
Primacy of patient interest
Placing the interest of the patient before all other external interests is the most
fundamental aspect of the medical profession and forms part of the unwritten
contract in the patient-physician relationship. This primacy also implies patient
autonomy in the determination of treatment.
?
Physician autonomy in medical decision making
While an increasing array of bureaucratic, administrative and economic forces
continue to limit physician autonomy, some degree of autonomy at the level of
medical decision making must be preserved by the physician in order to maintain
the primacy of interest.
?
Physician responsibility and accountability
The practice of medicine incurs responsibility and accountability to:
A. Patients
37
B. Colleagues
C. Society
D. Self
?
Humanistic qualities and altruism
Physicians should provide compassionate care and serve all patients with
respect to their cultural, emotional, spiritual and social needs.
?
Ethical behavior
This includes being trustworthy and cognizant of conflicts of interest. Integrity as
a physician and consultant rheumatologist must pervade all of the components of
professionalism.
Methods for Acquisition
Professionalism can be fostered throughout the fellowship training period beginning with
an emphasis on the essential components of professionalism and the specific
performance goals at the beginning of the fellowship.
?
Faculty role modeling. A culture of professionalism in the training
environment is created by mentors, role model clinicians, and a resident
culture that demonstrate the values of professionalism and a spirit of
collegiality in placing the needs of patients first, maintaining a commitment to
scholarship, helping colleagues meet their responsibilities, establishing a
commitment to continuous quality improvement, and being responsive to
society’s healthcare needs. A commitment to professional ethics is
demonstrated by establishing and maintaining a high standard of moral and
ethical behavior within the clinical setting in the care of patients, in the
education of residents, in conducting research, and in interacting with medical
device and pharmaceutical companies and funding organizations.
?
Participation in professional activities. Trainees should be given the
opportunity to participate in community service, professional organizations,
and institutional committee activities.
?
Clinical experience in a supervised, mentored clinical setting - to provide
experiential learning opportunities to observe and practice the key
components of professionalism. Faculty can be encouraged to highlight
pertinent professional issues with their fellows at the bedside, at weekly
conferences, and in the outpatient clinic setting.
?
Didactic teaching - conferences, lectures, or discussions devoted to topics of
professionalism. These might also include instructive case conferences using
case scenarios to highlight professionalism and ethical issues.
38
?
Faculty-facilitated group discussions. Case vignettes or journal club
discussions of issues of professionalism that provide the opportunity for frank
discussions between faculty and trainees about these issues.
?
Independent reading. Reading assignments of peer reviewed publications
and specialty organization publications from the AMA, ABIM, ACP, ACGME
and web-based discussions on professionalism.
Performance Markers
By the end of their training, fellows should be able to demonstrate competency in the
following areas:
?
Patient Primacy - the fellow should be able to:
A. Demonstrate responsiveness to the needs of patients that supercedes self-
interest.
B. Demonstrate sensitivity and attention to the interests of own patients in
formulation of treatment plans.
C. Demonstrate the ability to provide autonomy to their patients to decide upon
treatment once all treatment options and risks have been outlined for them.
D. Provide and obtain key elements of informed consent in an understandable
manner for therapeutic interventions and clinical research endeavors.
?
Physician Autonomy - the fellow should be able to demonstrate independent
medical decision-making skill.
?
Physician accountability and responsibility including:
A. Demonstrates timeliness and reliability in clinical care of patients, including
completion of medical records and in responding to patient calls and
requests.
B. Reliably follows through on duties and clinical tasks, including timely
response to calls from colleagues. Exhibits regular attendance and active
participation in divisional and departmental training activities and scholarly
endeavors.
C. Strives for excellence in care and scholarly activities as a rheumatologist.
D. Works to maintain personal physical and emotional health and demonstrates
an understanding of and ability to recognize physician impairment in self and
colleagues.
?
Humanistic qualities and altruism
A. Exhibits empathy and compassion in physician-patient interactions and is
sensitive to patient needs for comfort and encouragement.
39
B. Is courteous and respectful in interactions with patients, staff and colleagues.
C. Treats all patients with respect regardless of race, gender, ethnic, religious or
socioeconomic background.
D. Provides equitable care to all patients.
E. Demonstrates culturally competent care, which is defined here as the ability
to deliver effective medical care to patients, regardless of cultural or language
differences between the patient and the physician.
?
Ethical behavior
A. Demonstrates a commitment to ethical principles relating to provision and
withholding of clinical care, confidentiality of patient information and business
practices.
B. Is trustworthy in following through on clinical questions, laboratory results,
and other patient care responsibilities.
C. Recognizes and addresses actual and potential conflicts of interest including
pharmaceutical industry involvement in their medical education and program
funding and guarding against this influencing their current and future
prescribing habits.
D. Demonstrates integrity in reporting clinical and research findings to
supervisors and colleagues.
Evaluation Methods
It is very important to utilize measures that accurately evaluate professionalism.
Providing feedback to the fellows will allow constructive or corrective action to be taken
in the final phase of their medical education prior to embarking on their career when,
although frequently proceeding without any specific supervision, they remain
accountable to their patients, society, their peers and themselves.
?
Faculty performance rating - with regard to demonstration of professional
behavior
?
360 evaluations – regarding professional attitudes and behavior. Fellows may
also fill out self-evaluations in the sphere of professionalism and compare it to
responses from others for self-reflection and self-improvement.
?
Portfolio review – which should include a section to include reflective entries
on issues of professionalism such as difficult patient and peer encounters,
conflicts of interest, and barriers to providing equitable care.
?
Patient survey - with components that specifically address trainee’s
professionalism.
40
Suggested Reading List and Web Links
1. Rothman DJ, Medical professionalism - focusing on the real issues, N Engl J Med
2000;342:1284-6.
2. Klein EJ, Jackson JC, Kratz L, Marcuse EK, McPhillips HA, Shugerman RP, Watkins
S, Stapleton FB, Teaching professionalism to residents, Acad Med. 2003
Jan;78(1):26-34.
3. Hatem CJ. Teaching approaches that reflect and promote professionalism. Acad
Med. 2003 Jul;78(7):709-13.
4. Steinert Y, Cruess S, Cruess R, Snell L, Faculty development for teaching and
evaluating professionalism: from programme design to curriculum change, Med
Educ. 2005 Feb;39(2):127-36.
5. McCormick BB, Tomlinson G, Brill-Edwards P, Detsky AS, Related Articles, Effect of
restricting contact between pharmaceutical company representatives and internal
medicine residents on post-training attitudes and behavior, JAMA. 2001 Oct 24-
31;286(16):1994-9.
6. “Advancing Education in Professionalism.” An educational resource developed by
the ACGME to aid program directors in teaching and assessing professionalism
located at
http://www.acgme.org/outcome/implement/Profm_resource.pdf
7. The ACGME provides several assessment tools for the evaluation of
professionalism at
http://www.acgme.org/outcome/assess/profIndex.asp
8. The ACGME also has a comprehensive list of professionalism references available
at
http://www.acgme.org/outcome/comp/refProf1.asp
9. In 1995 the American Board of Internal Medicine published a monograph: Project
Professionalism; it was last reprinted in 2001 and can be accessed at
http://www.abim.org/pdf/profess.pdf
A very comprehensive document covering multiple issues facing medical
professions today and in the future.
10.The American Medical Association Ethics Publication “Virtual Mentor” found at
www.virtualmentor.org
.
Faculty members and fellows can subscribe at no charge. This can be utilized with
the trainees as a self-reading program or as a basis for discussion forums. The
January 2005, volume 7 Number 1 issue of this publication was devoted in its
entirety to challenges to professionalism which confront internal medicine residents
and fellows in a case based format. The following general areas are covered in
detail:
Patient-Physician
Relationships;
Informed
Consent;
Privacy
and
Confidentiality; Medical Student Participation in Patient Care; End-of-Life Care;
Conflicts of Interest; Access to Care.
11.The Association of American Medical Colleges and National Board of Medical
Examiners published the proceedings of a conference focusing on professionalism
in undergraduate medical education in 2002: "Embedding Professionalism in
Medical Education: Assessment as a tool for implementation." This can be accessed
at
http://www.nbme.org/PDF/NBME_AAMC_ProfessReport.pdf
41
This document provides useful information for medical educators in general to
include topics of professionalism into medical school curricula.
42
Appendices
Appendix A. The Competencies in a Specialized Clinic or
Rotation: Lupus Clinic
This is as an example of how a specialized clinic or rotation may be shown to address
the competencies in some generic and some unique ways. Throughout this description,
notations are included to note that a specific activity relates to one or more general
competencies. The competencies are abbreviated as follows:
PC – Patient care
MK – Medical knowledge
PL – Practice-based learning and improvement
IC
– Interpersonal and communication skills
PF – Professionalism
SP – Systems-based practice
Lupus Clinic
The Goals and Objectives of the Lupus Clinic rotation are:
1. To allow rheumatology trainees to enhance their medical knowledge of the
pathophysiology, clinical features, diagnosis and management of SLE, lupus
subtypes and other autoimmune connective tissue diseases through supervised
patient care in an outpatient setting. (MK, PL)
2. To enable trainees to become competent in the longitudinal care of patients with
SLE and to recognize how to diagnose and manage disease flares, infection and
other comorbid illnesses and the side effects of medications. (PC)
3. To enable trainees to diagnose and prevent those disease-related and treatment-
related complications that lead to long term morbidity such as avascular necrosis,
osteoporosis, and cardiovascular disease. (PC)
4. To enable trainees to enhance their interpersonal and communication skills in
dealing with the complex cultural, social, emotional and economic burden of a
serious chronic illness such as SLE. (IC)
5. To instruct trainees on the important systems-based practice issues including the
internal and external systems that contribute to the betterment or detriment of the
health care of these SLE patients and the practice of evidence-based cost
effective care. (SP)
6. To develop practice-based learning skills in the trainees to help deal with the
complicated diagnostic and therapeutic challenges these SLE patients present. (PL)
7. To involve trainees in ongoing research studies in SLE, including laboratory
studies of aberrant immune function, clinical outcome studies including
therapeutic infusion studies with new biological agents, research ethics, and the
consent process. (MK, PF)
43
Timeline:
End of Year 1. Trainees should have acquired extensive knowledge of the
pathophysiology and clinical features of SLE and its subtypes, the methods used to
diagnose SLE and evaluate disease activity, the medical therapies for autoimmune
connective tissue diseases and their side effects. Trainees will also have first hand
knowledge of the impact of these chronic illnesses on patients and their families, the
obstacles to providing optimal health care for this population and the systems available
to help overcome these issues. These skills will have employed all of the general
competencies.
End of Year 2. Trainees should be able to independently and comprehensively manage
the longitudinal care of patients with SLE. Such care includes attention to multisystem
involvement by the disease, the frequently multidisciplinary care required, and the
psychological support systems needed by these patients.
Description:
The rheumatology fellows have a weekly rotation in Lupus Clinic for 2 years. Each
fellow has a panel of patients and is supervised by a faculty attending (PC, MK). An
electronic medical record (ERM) used for all rheumatology patients is being utilized in
this clinic; our fellows have already noted areas in the ERM where recording lupus-
specific clinical and laboratory data could be improved (SP). This has resulted in a
quality improvement project spearheaded by some fellows and attendings to develop a
lupus module within the ERM to better document those specific diagnostic and
treatment issues of this population (PC, MK, PL, SP). The Fellows have to address
complicated and expensive patient management issues and must make decisions about
admission of acutely ill lupus patients to the hospital (PC, MK, SP). When necessary,
these lupus patients are admitted to the Rheumatology Teaching Service and inpatient
management is coordinated and supervised by the fellow who works with and teaches
the medical housestaff team (PC, PL, IC, PF).
Multiple health care providers must be called upon to assist in the management of lupus
patients; this includes nursing, radiology, dermatology, nephrology, neurology, social
work, orthopedics and physical therapy (PC, IC, PF, SP). Some patients speak English
poorly and an interpreter is required (IC, SP, PF). Many patients need financial
assistance in obtaining appropriate medications, emotional support in dealing with their
illness, help with letters for absence from work and assistance in filing for disability
benefits (PF, IC, SP). Some patients are nonadherent to their medical regimens for
social or financial reasons and alternative approaches to their management may be
needed (IC, PF, SB). Clinic visits address comorbid illnesses, such as diabetes and
hypertension, and side effects of therapy (PC, MK, PL). The local Lupus Foundation
provides assistance to many patients and the faculty and fellows participate in their
programs (IC, SP). Fellows must frequently research the literature about diagnostic and
therapeutic problems related to these complicated patients both for patient care and for
clinical conferences (PC, MK, PL). Research studies are being conducted in this lupus
44
population and the fellows participate in identifying appropriate patients, obtaining
informed consent and in some cases being the principal investigators on the projects
(MK, IC, PL). Some of these studies involve the infusion of biologic modulators in a
rheumatology infusion center and fellows see the occasional research patient to
address adverse events (PC, MK).
Core Competency Acquisition in the Lupus Clinic
COMPETENCY
ACTIVITY
SCE
DID
SDL
DEM
Patient care (PC)
X
X
X
X
(infusions of
