The subspecialty of rheumatology includes a wide array of autoimmune, inflammatory, and non-inflammatory conditions 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.
Recognition 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 health professionals (Nurses, Nurse Practitioners, Physician Assistants, etc.) 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.
Core Curriculum
Organized by the Core competencies
(Methods of teaching/evaluation and expectations by level of training)
(Methods of teaching/evaluation and expectations by level of training)
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Medical Knowledge
Required Skills
1. Demonstrate analytical thinking when approaching clinical situations
a)Teaching Methods
-Introduction to Rheumatology core curriculum lectures
-Presentations given at divisional lectures (particularly grand rounds)
-Attendance and participation at divisional lectures
-Consultation Service rounds
-Case presentation and discussion in teaching clinics
b)Evaluation Methods (Frequency and Feedback)
-Daily direct observation and feedback by attendings and program director
-Monthly MiniCEX and feedback
-Monthly formative attending evaluation and feedback
-Semi-Annual 360 evaluation exercise and feedback
-Semi-Annual program director evaluation and feedback
-Performance in yearly National Rheumatology InService examination
-Performance in American Board of Internal Medicine certifying examination in Rheumatology
-Preparation and submission for publication of clinical manuscript to peer-reviewed journal
2. Knowledge and application of basic and clinical science concepts in Rheumatology (see details below)
a)Teaching Methods
-Introduction to rheumatology core curriculum lectures
-Presentations given at divisional lectures (particularly grand rounds)
-Attendance and participation at divisional lectures
-Consultation Service rounds
-Case presentation and discussion in teaching clinics
-ACR National Meeting and Workshops
-ACR State of the Art Meeting
b)Evaluation Methods (Frequency and Feedback)
-Daily direct observation and feedback by attendings and program director
-Monthly MiniCEX and feedback
-Monthly formative attending evaluation and feedback
-Semi-Annual 360 evaluation exercise and feedback
-Semi-Annual program director evaluation and feedback
-Performance in annual National Rheumatology InService examination
-Performance in American Board of Internal Medicine certifying examination in Rheumatology
-Preparation and submission for publication of clinical manuscript to peer-reviewed journal
MEDICAL KNOWLEDGE AREAS-Basic Sciences and Clinical Sciences
Basic Sciences
The methods and resources include structured didactic lectures, recommended textbooks, journal articles, regional and national seminars, laboratory experience, video and computer based activities. The fund of knowledge obtained through this curriculum serves as the foundation for understanding the pathogenesis, diagnosis, and treatment of the rheumatic diseases. Subjects include the following:
A. Anatomy and biology of musculoskeletal tissues: for each tissue,
understand the embryology, development, biochemistry and
metabolism, structure, function, and classification
1. Joints and ligaments: diarthrodial joints, intervertebral discs,
synovium, cartilage
2. Connective tissue cells and components: fibroblasts, collagens, proteoglycans, elastin, matrix glycoproteins
3. Bone
4. Muscle and tendons
5. Blood vessels
B. Immunology
1. Anatomy and cellular elements of the immune system
a. Lymphoid organs: gross and microscopic anatomy and
function
b. Specific cells: for each cell type, understand the ontogeny, structure, phenotype, function, and activation
markers/receptors
(1) Monocytes and macrophages
(2) Lymphocytes: T cells, B cells, null cells
(3) Neutrophils and eosinophils
(4) Other cells: dendritic cells, mast cells, platelets,
endothelial cells, and fibroblasts
2. Immune and inflammatory mechanisms
a. Antigens: types, structure, processing, presentation, and
elimination
b. Superantigens: types, site of binding, and effect on immune
system
c. Major histocompatibility complex: structure, function,
nomenclature, and immunogenetics
d. B cell receptors/immunoglobulins: structure, function, antigen
binding, signaling, genetic basis, effector function
e. T cell receptors: structure, function, antigen binding,
signaling, genetic basis
f. Receptor ligand interactions: adhesion molecules,
complement receptors, Fc receptors, and signal
transduction
g. Complement/Kinin systems: structure, function, and regulation
h. 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
b. Cytokines: for each cytokine, understand the origin, structure,
effect, site of action, metabolism, regulation, and gene
activation
c. Inflammatory mediators: for each mediator, understand the
origin, structure, effect, site of action, metabolism, and
regulation
4. Immune responses
a. IgE mediated: acute and late phase reactions
b. Immunoglobulin mediated: opsonization, complement fixation,
and antibody dependent cellular cytotoxicity
c. Immune complex mediated: physiochemical properties and
clearance of immune complexes
d. Cell mediated: cells and effector mechanisms in cellular
cytotoxicity and granuloma formation
e. Mucosal immunity: interactions between gut and bronchus-
associated Iymphoid tissue and secretory IgA
f. Other: natural killers, Iymphokine activated killer, graft versus
host reaction
5. Immunoregulation
a. Tolerance: clonal selection, deletion, energy, and antigen
paralysis
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. Laboratory and diagnostic tests
1. Laboratory tests: for each test, understand the biology and
principles/methodology of the laboratory techniques
a. Erythrocyte sedimentation rate, C reactive protein, and acute
phase reactants
b. Rheumatoid factors and Anti-CCP antibodies
c. Antinuclear/anticytoplasmic antibodies: screening test, specific
autoantibody tests, and LE cell preparation
d. Antineutrophil antibodies: membrane and cytoplasmic
e. Antiphospholipid antibodies including RPR, lupus
anticoagulant, and anticardiolipin antibodies
f. Others: total serum complement activity, complement
proteins, histocompatibility markers, complotypes,
cryoglobulins, immunoglobulin levels
2. Synovial fluid analysis: cell count and differential, crystal
identification, viscosity, protein, glucose, and other special
stains/analyses
3. Radiographic imaging and other diagnostic procedures: understand
principles and methodology of the following tests:
a. Plain radiographs of bone and joints
b. Bone densitometry
c. Nuclear medicine scintigraphy
d. Ultrasonography and arthrography
e. Computed tomography
f. Magnetic resonance imaging
g. Electromyography and nerve conduction velocities
4. Test performance characteristics: principles of sensitivity, specificity,
and predictive value
E. 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
F. Research principles in basic and clinical investigation
1. Principles of epidemiology and health services research
2. Design of experimental protocols, clinical trials, and outcomes
research
3. Laboratory techniques
a. Serologic: ELISA, RIA, RID, nephelometry, immunoblots,
protein electrophoresis, circulating immune complex
assays
b. Cellular: lymphocyte proliferation, flow cytometry
c. Histochemistry and immunofluorescence of biopsied tissues
d. Molecular: Northern, Southern, Western, polymerase chain
reaction, genetic mapping techniques, gene sequencing
e. Hybridoma and monoclonal antibody production
f. Transgenic and gene knock out animals
g. Principles of gene therapy
4. Data analysis, biostatistics, meta analysis and medical informatics
5. Health status, disease activity, accumulated damage, functional, and
quality of life measurements/assessments
6. Bioethics of basic research and clinical trials
7. Critical literature review
Clinical Sciences
The subspecialty of rheumatology includes a wide array of inflammatory, noninflammatory, and degenerative diseases that affect the musculoskeletal and other organ systems. The purpose of our rheumatology training program is to train fellows to be accomplished practitioners and consultants in the rheumatic diseases. Moreover, the scholarly attitude and approaches to maintain an understanding of current concepts in rheumatology as advances occur are emphasized.
The following is an outline of clinical knowledge which each rheumatology fellow is trained to possess in order to diagnose and effectively treat rheumatic diseases. Teaching methods include clinical experience, didactic lectures, self learning from recommended textbooks and journal articles, seminars, journal clubs, visiting faculty, case related conferences, courses at regional and national meetings, grand rounds, quizzes, video/audio cassettes, and computer based activities. By the end of their training, each fellow will have sufficient exposure to the rheumatic diseases in order to serve as a physician with specific knowledge and expertise in rheumatology. All fellows are trained in epidemiology, symptomatology and physical findings, pathophysiology, diagnosis, differential diagnosis, prognosis, and treatment of each disease. Additionally, fellows receive instruction on the emotional and socioeconomic factors that influence or result from the rheumatic diseases.
The list in its entirety is comprehensive. Special emphasis is given to some conditions. In particular to formal instruction, clinical experience and demonstration of competence in the prevention, evaluation and management of the following:
a) rheumatoid arthritis;
b) systemic lupus erythematosus;
c) scleroderma/systemic sclerosis;
d) polymyositis;
e) spondyloarthropathies;
f) vasculitis;
g) crystal-induced synovitis;
h) osteoarthritis;
i) regional musculoskeletal pain syndromes, and acute and chronic
musculoskeletal pain syndromes;
j) nonarticular rheumatic diseases, including fibromyalgia;
k) nonsurgical, exercise-related (sports) injury;
l) systemic diseases with rheumatic manifestations;
m) metabolic diseases of bone;
n) osteoporosis;
o) infection of joints and soft tissues; and
p) Sjogren’s Syndrome.
A. Rheumatic Diseases
1. Systemic connective tissue diseases: rheumatoid arthritis, lupus
erythematosus (systemic, discoid, and drug related), scleroderma
(localized syndromes, systemic sclerosis, CREST variant,
chemical/drug related), eosinophilic fasciitis, eosinophilic myalgic
syndrome, Sjogren's syndrome, polymyositis and
dermatomyositis, overlap syndromes including mixed connective
tissue disease, polymyalgia rheumatica, relapsing polychondritis,
relapsing panniculitis, erythema nodosum, adult onset Still's
disease, primary antiphospholipid antibody syndrome,
undifferentiated connective tissue disease
2. Seronegative spondylarthropathies: ankylosing spondylitis, Reiter's
syndrome, psoriatic arthritis, inflammatory bowel disease-
associated arthritis, arthritis associated with acne and other skin
diseases, SAPHO syndrome, and undifferentiated
spondylarthropathies
3. Vasculitides: temporal arteritis, Takayasu's arteritis, polyarteritis
nodosa and systemic necrotizing vasculitis overlaps, allergic
granulomatosis of Churg Strauss, Wegener's granulomatosis and
other ANCA associated diseases, Behcet's disease,
hypersensitivity and small vessel angiitis, cryoglobulinemia,
Cogan's syndrome
4. Pediatric rheumatic diseases: diseases occurring primarily in
childhood (e.g., juvenile rheumatoid arthritis, Kawasaki's disease
and infantile PAN, neonatal lupus syndrome, juvenile
dermatomyositis, acute rheumatic fever, bone and joint
dysplasias, other) and diseases which occur primarily in adults
but can occur in childhood (e.g., SLE, systemic sclerosis, others)
5. 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
6. Metabolic, endocrine, and hematologic disease associated rheumatic
disorders
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 Iymphadenopathy
7. Bone and cartilage disorders
a. Osteoarthritis primary and secondary osteoarthritis,
chondromalacia patella
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
8. 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. Others: hemochromatosis, familial Mediterranean fever,
hyperlipidemic arthropathy, myositis ossificans progressive,
Wilson's disease, others
9. Nonarticular and regional musculoskeletal disorders
a. Fibromyalgia
b. Psychogenic rheumatism
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 illnesses: in addition to bursitis,
tendonitis, or enthesitis occurring around each joint, the
fellow will 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
10. 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
11. Muscle diseases
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
12. 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. Clinical and technical skills
1. Rheumatologic history: understand principles and demonstrate
competency in obtaining a clinical history, relevant review of
systems, and functional status of patients with rheumatic disease
symptoms
2. Physical examination: 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 will be able to identify extraarticular
findings that are associated with specific rheumatic diseases
3. Diagnostic testing and procedures
a. Arthrocentesis: 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
b. Synovial fluid analysis: understand the principles and
interpretation of results of synovial fluid analyses and
demonstrate competency in the analysis of synovial fluid
by light and polarized microscopy from patients with a
variety of rheumatic disorders
c. Interpretation of results of specific laboratory tests (including
but not limited to): erythrocyte sedimentation rate, C-
reactive protein and other acute phase reactants, iron
studies including ferritin, rheumatoid factor, antinuclear
antibodies, anti ds DNA, anti SS A/Ro, anti SS B/La, anti Ul
RNP, anti Sm. antiribosomal P, anticentromere, anti
topoisomerase 1, anti Jo 1, anti PM Scl, antineutrophil
cytoplasmic antibodies, cryoglobulins, complement
component levels, CH50, serum protein electrophoresis,
serum immunoglobulin levels, LE cell preparation, RPR,
lupus anticoagulant, anticardiolipin antibodies, HLA typing
(e.g., HLA B27), antihistone antibodies, ASO and other
streptococcal antibody tests, Lyme serologies, serum and
urine uric acid levels, circulating immune complexes,
Iymphocyte subset and function data, anticellular
antibodies (e.g., Coomb’s, neutrophils, platelets)
d. Plain radiographs: demonstrate understanding and competency
in the assessment of radiographs of normal and diseased
joints, bones, periarticular structures, and prosthetic joints
e. Demonstrate competency in the interpretation of results from
the following tests in patients with rheumatic diseases
(fellows may develop skill in the performance of some of
these tests):
(1) Diagnostic imaging techniques: arthrography,
ultrasonography, computed tomography, magnetic
resonance imaging of joints, bones, and periarticular
structures
(2) Radionuclide scanning techniques: joint and bone
scans, parotid scans and salivary flow studies, bone
densitometry
(3) Arteriograms in the vasculitides
(4) Electromyograms and nerve conduction studies
(5) 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
(6) Others: nailfold capillary examination (microscopy),
ischemic forearm muscle test, Schirmer's and rose
bengal tests, closed needle synovial biopsy, and
arthroscopy
4. 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.
5. Using the basic principles of decision analysis, understand the
indications for and costs of ordering laboratory tests and
procedures to establish a diagnosis of a rheumatologic disease.
C. Therapeutic modalities and strategies
1. Therapeutic aspiration and injection: understand the anatomy,
precautions, and potential sequellae of and demonstrate
competency in therapeutic aspiration and/or injection of
diarthroidal joints, bursae, tenosynovial structures, and entheses.
2. 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.
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. Immunomodulators: cyclosporine, biologic response modifiers
f. Hypouricemic drugs: allopurinol, sulfinpyrazone, probenecid
g. Antibiotic therapy for septic joints
h. Narcotic and non narcotic analgesics
i. Others: apheresis, ionizing radiation
3. Rehabilitation, disability, and pain management issue
a. Multidisciplinary team concept: 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 identify physical impairment;
relate the impairment to the observed functional deficits;
prescribe appropriate rehabilitation to achieve goals to
improve the defined impairment
c. Methods of rehabilitation: for each method, understand
principles, mechanism of action, indications, precautions
and contraindications, potential side effects, and costs
(1) Exercise: range of motion, strengthening conditioning,
and stretching
(2) Rest and splinting
(3) Modalities and hydrotherapy: ultrasound,
iontophoresis, spa therapy
(4) Joint protection and energy conservation techniques
(5) Adaptive equipment and assistive devices
(6) Job site/home evaluation and adaptation
(7) Footwear and orthotics
(8) Others: acupuncture, TENS unit, pain clinics, traction
(9) 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: 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) Psychologic 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
f. Rehabilitation of the rheumatic disease patient after a surgical
or orthopedic procedure
4. Surgical management
a. Understand indications for surgical and orthopedic
consultation in acute and chronic rheumatic diseases.
b. For each procedure, the fellow should possess a working
knowledge of indications, preoperative evaluation and
medication adjustments, contraindications, complications,
postoperative management, and expected outcome
(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:
(a) Pediatric rheumatic disease patient
(b) Infected joint: arthroscopy vs. arthrotomy
(c) Infected prosthetic joint
(d) Ankylosing spondylitis patient
(e) Prevention and treatment of deep venous
thrombosis
5. Unconventional medical practices: diet, nutritional supplements,
antimicrobials, acupuncture, topicals, homeopathic remedies,
venoms, others
6. Using the basic principles of decision analysis, understand the
indications for and cost of different therapies used in the
management of rheumatic diseases
Professional Knowledge and Ethics
All rheumatology fellows will not pursue the same career goals upon completion of the training program. Most will join a group in private practice, others will set up their own practice, select an an academic career in clinical medicine and/or research, and some go into industry. In order to make an informed choice and prepare the fellow for his/her future profession, the specific knowledge outlined below is provided. Local and visiting faculty with specific expertise in these areas (e.g. private practitioners, etc.) are used
A. Teaching and presentation skills
1. Teaching skills: understand principles of effective teaching and
their application with respect to learning objectives, format (e.g.,
lecture, group discussion, etc.), and assessment
2. Presentation skills: poster, podium, carousel and overhead projector
slides, other.
3. Patient Education
B. Writing skills: understand principles of how to write grants, manuscripts,
and/or consultation reports
C. 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
D. The fellow will be familiar with the history of rheumatology, American
College of Rheumatology, Arthritis Foundation, Arthritis Health
Professions Association, and Multipurpose Arthritis Centers
E. The fellow will be familiar with the role of rheumatology in organizations such as
American Medical Association, Food and Drug Administration, HICFA
and other governmental agencies involved in health care legislation, Peer Review Organizations
F. Ethical issues as to the practice of rheumatology will be discussed in the fellows conference at least twice a year
Expectations by level of training
First Year Fellow-
A)The first year fellow will be expected to demonstrate his ability for analytical thinking and application of his knowledge in the basic and clinical science in the care of his patients. This will not only be demonstrated by interactions in clinic and the consultation service but also in the setting of the multiple teaching conferences.
Second Year Fellow-
A)The second year fellow will be expected to be proficient in all the first year requirements and will in addition be able to actively participate at a more advanced level in discussions during conferences and in the clinical settings.
B)He will also be expected to demonstrate his knowledge base in his interactions with medical students and residents.
C)His presentations in conferences such as grand rounds, journal club and research conference will be more in depth and demonstrate a mastery of the subjects presented.
D)Second year fellows will also participate in the scheduling of conference including selection of topics and speakers.
-
Patient Care
Required Skills
Communicates effectively and demonstrates caring and respectful behavior when interacting with patients and families.a)Teaching Methods
-Role modeling
-Case presentation and discussion in teaching clinics
-Consultation service rounds
b)Evaluation Methods (Frequency and Feedback)
-Daily direct observation and feedback by attendings and program director
-Monthly MiniCEX forms and feedback
-Monthly formative attending evaluations and feedback
-Semi-Annual 360 evaluation exercise and feedback
-Semi-Annual program director evaluation and feedback2. Gather essential and accurate information about patients. (Comprehensive history and physical examination with particular attention to the rheumatologic/musculoskeletal examination)
a)Teaching Methods
-Role modeling
-Introduction to Rheumatology core curriculum lectures
-Consultation Service rounds
-Case presentations and discussion in teaching clinics
b)Evaluation Methods (Frequency and Feedback)
-Daily direct observation and feedback by attendings and program director
-Monthly MiniCEX forms and feedback
-Monthly formative attending evaluations and feedback
-Semi-Annual 360 evaluation exercise and feedback
-Semi-Annual program director evaluation and feedback
3. Make informed diagnostic and therapeutic decisions based on patient information and preferences using the latest scientific evidence and appropriate clinical judgment. (Uses laboratory and imaging studies appropriately. Has appropriate knowledge of the pathophysiology, diagnosis and management of the rheumatologic diseases as listed in the core curriculum. Constructs appropriate differential diagnoses for rheumatologic symptoms and signs)
a)Teaching Methods
-Introduction to Rheumatology core curriculum lectures
-Divisional lectures
-Consultation Service rounds
-Case presentation and discussion in teaching clinics
b)Evaluation Methods (Frequency and Feedback)
-Daily direct observation and feedback by attendings and program director
-Monthly MiniCEX and feedback
-Monthly formative attending evaluation and feedback
-Semi-Annual 360 evaluation exercise and feedback
-Semi-Annual program director evaluation and feedback
4. Develop and execute patient management plans (Knowledge of rationale for use, indications, contraindications potential risks and benefits and alternatives to treatment with the medications used to treat rheumatic diseases including NSAIDs, corticosteroids, DMARDs, antihyperuricemic drugs, antiobiotics and others)
a)Teaching Methods
-Introduction to Rheumatology core curriculum lectures
-Divisional lectures
-Consultation Service rounds
-Case presentation and discussion in teaching clinics
b)Evaluation Methods (Frequency and Feedback)
-Daily direct observation and feedback by attendings and program director
-Monthly MiniCEX and feedback
-Monthly formative attending evaluation and feedback
-Semi-Annual 360 evaluation exercise and feedback
-Semi-Annual program director evaluation and feedback
5. Counsel and educate patients and their families
a)Teaching Methods
-Role modeling
-Divisional lectures
-Consultation Service rounds
-Case presentation and discussion in teaching clinics
b)Evaluation Methods (Frequency and Feedback)
-Daily direct observation and feedback by attendings and program director
-Monthly MiniCEX and feedback
-Monthly formative attending evaluation and feedback
-Semi-Annual 360 evaluation exercise and feedback
-Semi-Annual program director evaluation and feedback
6. Use information technology to support patient care decisions and patient education
a)Teaching Methods
-Role modeling
-Attendance and participation at divisional lectures
-Preparation of presentations at divisional lectures
-Consultation Service rounds
-Case presentation and discussion in teaching clinics
b)Evaluation Methods (Frequency and Feedback)
-Daily direct observation and feedback by attendings and program director
-Monthly MiniCEX and feedback
-Monthly formative attending evaluation and feedback
-Semi-annual program director evaluation and feedback
7. Perform and/or interpret results of procedures essential to the practice of rheumatology (Diagnostic aspiration of diarthrodial joints, bursae and tenosynovial structures; Therapeutic injection of diarthrodial joints, bursae, tenosynovial structures and enthuses; Interpretation of biochemical analysis of synovial fluid; Performance of light and polarized microscopy of synovial fluid; Knowledge of rationale, alternatives, indications, contraindications, risks, benefits, costs, expected outcomes and interpretation of results of diagnostic aspiration and therapeutic injection, EMG/NCS, skin biopsies, renal biopsies, muscle biopsies, blood vessel biopsies, angiography, radiography including plain radiographs, MRI, CT, DXA and others, nailfold capillaroscopy, joint replacement surgery and arthroscopy)
a)Teaching Methods
-Role modeling
-Introduction to Rheumatology core curriculum lectures
-Divisional lectures
-Consultation Service rounds
-Case presentation and discussion in teaching clinics
-ACR National Meeting Fellow Workshops
-ACR State of the Art Meeting
b)Evaluation Methods (Frequency and Feedback)
-Daily direct observation and feedback by attendings and program director
-Monthly MiniCEX and feedback
-Monthly formative attending evaluation and feedback
-Semi-Annual 360 evaluation exercise and feedback
-Semi-Annual program director evaluation and feedback
-Arthrocentesis and injection logbook and semi-annual feedback
-Annual National Rheumatology InService examination
8. Provide health care services aimed at preventive interventions or maintenance of health
a)Teaching Methods
-Role modeling
-Introduction to Rheumatology core curriculum lectures
-Divisional lectures
-Consultation Service rounds
-Case presentation and discussion in teaching clinics
b)Evaluation Methods (Frequency and Feedback)
-Daily direct observation and feedback by attendings and program director
-Monthly MiniCEX and feedback
-Monthly formative attending evaluation and feedback
-Semi-Annual 360 evaluation exercise and feedback
-Semi-Annual program director evaluation and feedback
9. Learn to work with other health care professionals, including nurses, physical therapists, others that are encountered in the provision of health care
a)Teaching Methods
-Role modeling
-Interactions in teaching clinics
-Interactions during inpatient consultation service rounds
b)Evaluation Methods (Frequency and Feedback)
-Daily direct observation and feedback by attendings and program director
-Monthly MiniCEX and feedback
-Monthly formative attending evaluation and feedback
-Semi-Annual 360 evaluation exercise and feedback
-Semi-Annual program director evaluation and feedback
Expectations by year of training
First Year Fellows-
A)They will be assisted in the development of their skills in obtaining a history from the patient with Rheumatic Disease.
B)They will attain proficiency in the musculoskeletal examination and the assessment and differential diagnoses in Rheumatic Diseases.
C)They will attain proficiency in arthrocentesis and soft tissue injection.
D)They will learn about the microscopic analysis of synovial fluid.
Second Year Fellows-
A)The second year fellow will be expected to have attained sufficient knowledge and skill in the evaluation and management of rheumatic disease to enable them to serve as teachers for medical students and rotators.
B)They will have ample opportunity in the clinic and consultation service to display their teaching talents.
C)They will also help in the training of the first year fellows.
D)They will attend both the ACR National Meeting and the ACR State of the Art meeting including fellow workshops on crystal examination and ethics/professionalism sessions. -
Professionalism
Required skills
1. Demonstrate respect, compassion and integrity (Responsive to the needs of patients and society; accountability to patients, society and the rheumatologic community; Commitment to excellence and ongoing professional development)
a)Teaching Methods
-Role Modeling
-Divisional lectures
-Consultation Service rounds
-Case presentation and discussion in teaching clinics
-Showing of film-“The Choice is Yours” and discussion to promote self-reflection
b)Evaluation Methods (Frequency and Feedback)
-Daily direct observation and feedback by attendings and program director
-Monthly MiniCEX and feedback
-Monthly formative attending evaluation and feedback
-Semi-annual program director evaluation and feedback
2. Commitment to ethical principles, particularly those related to provision or withholding of care, confidentiality of patient information, informed consent and business practices
a)Teaching Methods
-Role Modeling
-Divisional lectures
-Consultation Service rounds
-Case presentation and discussion in teaching clinic
-Showing of film-“The Choice is Yours” and discussion to promote self-reflection
-Attending the ACR National Meeting and Workshops
-Attending the ACR State of the Art Course (Including fellows ethics session)
b)Evaluation Methods (Frequency and Feedback)
-Daily direct observation and feedback by attendings and program director
-Monthly MiniCEX and feedback
-Monthly formative attending evaluation and feedback
-Semi-annual program director evaluation and feedback
3. Demonstrate sensitivity and responsiveness to patients’ cultural and social circumstances. Sensitivity and responsiveness to age, gender and disability differences in patients.
a)Teaching Methods
-Role Modeling
-Divisional lectures
-Consultation Service rounds
-Case presentation and discussion in teaching clinics
-Showing of film-“The Choice is Yours” and discussion to promote self-reflection
b)Evaluation Methods (Frequency and Feedback)
-Daily direct observation and feedback by attendings and program director
-Monthly MiniCEX and feedback
-Monthly formative attending evaluation and feedback
-Semi-annual program director evaluation and feedback
-360 Evaluations
Expectations for level of training
First year fellow-
A)The first year fellow will be closely monitored and evaluated in his outpatient clinics and the inpatient consultation service. This will allow for ample role modeling and one on one interactions with the attending faculty.
B) Fellows will be exposed and trained on ethical principles, particularly those related to provision or withholding of care, confidentiality of patient information (including HIPAA training on hospital orientation), informed consent and business practices. They will be expected to uphold the highest standards.
C)There will be early training in the application of sensitivity and responsiveness to the different cultural and social backgrounds of our patients as well as early demonstration of ethical principles, respect, compassion and integrity.
D) There will be exposure to audiovisual aides including a movie “The Choice is Yours” on the issues of ethical and end of life care.
Second year fellow-
A)The second year fellow will continue developing his professionalism and will receive frequent feedback on his performance. He will be expected to show a commitment to excellence.
B)The second year fellow will also serve, in turn, as a trainer on these issues of the first year fellows, residents and medical students.
C)The second year fellow will attend the ACR State of the Art conference in Chicago which as a whole day fellows session that includes a session on ethics/professionalism.
D)The fellow will alsop show a commitment to participation in the medical community locally and nationally through participation in ACR meetings and initiatives, the Florida Society of Rheumatology and through our “Rheumatology Grand Rounds in the Community” program.
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Systems-based Practice
Required Skills
1. Understanding how patient care and other professional behaviors can affect other health care professionals, health care systems and the larger society. Also understanding how health care systems affect their own practice.
a)Teaching Methods
-Divisional lectures
-Interdisciplinary Conference
-Medical grand rounds
-Ongoing systems improvement projects
b)Evaluation Methods (Frequency and Feedback)
-Daily direct observation and feedback by attendings and program director
-Monthly formative attending evaluation and feedback
-360 Evaluation by nurses, administrators, patients, residents and medical students, etc.
2. Know how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating health care resources
a)Teaching Methods
-Divisional lectures
-Interdisciplinary Conference
-Medical grand rounds
-Systems improvement projects
b)Evaluation Methods (Frequency and Feedback)
-Daily direct observation and feedback by attendings and program director
-Monthly formative attending evaluation and feedback
3. Practice cost-effective health care and resource allocation that does not compromise quality of care
a)Teaching Methods
-JMH clinics lab ordering programs
-Divisional lectures
-Interdisciplinary Conference
-Medical grand rounds
-Consultation Service rounds
-Case presentation and discussion in teaching clinics
-Ongoing systems improvement projects
b)Evaluation Methods (Frequency and Feedback)
-Daily direct observation and feedback by attendings and program director
-Monthly formative attending evaluation and feedback
4. Advocate for quality patient care and assist patients in dealing with system complexities.
a)Teaching Methods
-Divisional lectures
-Interdisciplinary Conference
-Medical grand rounds
-Consultation Service rounds
-Case presentation and discussion in teaching clinics
b)Evaluation Methods (Frequency and Feedback)
-Daily direct observation and feedback by attendings and program director
-Monthly formative attending evaluation and feedback
5. Know how to partner with health care managers and health care providers to assess, coordinate, and improve health care and know how these activities can affect system performance
a)Teaching Methods
-Divisional lectures
-Interdisciplinary Conference
-Medical grand rounds
-Consultation Service rounds
-Case presentation and discussion in teaching clinics
b)Evaluation Methods (Frequency and Feedback)
-Daily direct observation and feedback by attendings and program director
-Monthly formative attending evaluation and feedback
-360 Evaluations
6. Use information technology to manage information; access online medical information and support ongoing self-education
a)Teaching Methods
-Preparation of Divisional lectures
-Consultation Service rounds
-Case presentation and discussion in teaching clinics
-Fellows office and computer access
-Computer and internet access in clinics
-JMH clinics lab ordering program
b)Evaluation Methods (Frequency and Feedback)
-Daily direct observation and feedback by attendings and program director
-Monthly formative attending evaluation and feedback
7. Facilitate the learning of students and other health care professionals
a)Teaching Methods
-Preparation and delivery of divisional lectures
-Supervision of medical residents and students on elective
b)Evaluation Methods (Frequency and Feedback)
-Daily direct observation and feedback by attendings and program director
-Monthly formative attending evaluation and feedback
-360 Evaluations
Expectations by level of training
First year fellows-
A)The first year fellows will be trained in the resources available in information technology including the medical school and the divisional library. They will also gain confidence in using on line and computer based resources such as PubMed and the website of the American College of Rheumatology. They will demonstrate their knowledge gained in the utilization of these resources through the preparation and delivery of their conferences such as core curriculum conference, journal club and grand rounds.
B)They will also be expected to learn through exposure to role models in rheumatology that practice in a variety of settings in the health system. Thus, they will understand how types of medical practice and delivery systems differ from one another.
C)While rotating through our consultation services, they will learn to efficiently partner with health care managers and other health care providers in order to provide care as part of a health care team.
D)They will learn to provide cost effective health care without sacrificing quality of care.
E)They will participate in systems improvement projects.
Second year fellows-
A)In addition to mastery of information technology and the systems in medicine, the second year fellows will help in the development of systems improvement projects. They will also report on the results of these.
B)Second year fellows will also take a leading role in the facilitation of learning of students and other health care professionals rotating through our service or participating in our clinics.
C)They will be expected to exemplify continued self development through the use of information technology and other resources.
D)Furthermore, they will have developed into advocates for their patients’ health care.
E) Upon completion of the program, they will understand how patient care and other professional behaviors can affect other health care professionals, health care systems and the larger society. Also understanding how health care systems affect their own practice.
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Practice-based Learning and Improvement
Required skills
1. Analyze practice experience and perform practice-based improvement activities using a systematic methodology
a)Teaching Methods
-Divisional conferences (Grand rounds, Clinicopathologic Conference)
-Case presentation and discussion in teaching clinics
-Possible Project during research rotation
-Systems improvement projects
b)Evaluation Methods (Frequency and Feedback)
-Monthly formative attending evaluation and feedback
-Semi-annual program director evaluation and feedback
2. Locate, appraise and assimilate evidence from scientific studies related to their patients’ health problems
a)Teaching Methods
-Divisional Conferences (Grand Rounds, Journal Club)
-Preparation of Divisional lectures
-Consultation Service rounds
-Case presentation and discussion in teaching clinics
-Fellows office and computer access
-Computer and internet access in clinics
b)Evaluation Methods (Frequency and Feedback)
Daily direct observation and feedback by attendings and program director
-Monthly MiniCEX and feedback
-Monthly formative attending evaluation and feedback
-Semi-annual program director evaluation and feedback
3. Obtain and use information about their own population of patients and the larger population from the community
a)Teaching Methods
-Divisional Conferences (Grand Rounds, Journal Club)
-Preparation of Divisional lectures
-Consultation Service rounds
-Case presentation and discussion in teaching clinics
b)Evaluation Methods (Frequency and Feedback)
-Daily direct observation and feedback by attendings and program director
-Monthly MiniCEX and feedback
-Monthly formative attending evaluation and feedback
-Semi-annual program director evaluation and feedback
4. Apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness
a)Teaching Methods
-Divisional Conferences (Grand Rounds, Journal Club, Research Conference)
-Participation and observation of the conduct of clinical trials while on research rotation
b)Evaluation Methods (Frequency and Feedback)
-Daily direct observation and feedback by attendings and program director
-Research rotation evaluation
-Monthly formative attending evaluation and feedback
-Semi-annual program director evaluation and feedback
5. Use of information technology to manage information, access online medical information and support self-education
a)Teaching Methods
-Preparation of Divisional lectures
-Consultation Service rounds
-Case presentation and discussion in teaching clinics
-Self study while on research rotation
-Fellows office and computer access
-Computer and internet access in clinics
b)Evaluation Methods (Frequency and Feedback)
-Daily direct observation and feedback by attendings and program director
-Monthly formative attending evaluation and feedback
-Research rotation evaluation
6. Facilitate the learning of students and other health care professionals
a)Teaching Methods
-Preparation and delivery of divisional lectures
-Supervision of medical residents and students on elective
b)Evaluation Methods (Frequency and Feedback)
-Daily direct observation and feedback by attendings and program director
-Monthly formative attending evaluation and feedback
Expectation for level of training
First year fellows-
A)They will locate, appraise and assimilate evidence from scientific studies related to their patients’ health problems and demonstrate this ability not only in clinic and during teaching and working rounds but also in their grand rounds and journal club presentations.
B) They will obtain and use information about their own population of patients and the larger population from the community and apply this in investigations geared to practice-based improvement activities.
C) They will help in the design and conduct of practice based improvement projects that will help analyze their practice experience.
D) In conferences such as journal club, they will learn and apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness.
E) They will learn about the use of information technology to manage information, access online medical information and support self-education and demonstrate this knowledge both in clinical practice and in conferences. Facilitate the learning of students and other health care professionals
Second year fellows-
A)They will be the principal designers of practice based improvement activities that will help in analysis of the practice experience
B)They will facilitate the learning of student and other health care professionals on elective, in clinic or in the consultation service.
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Interpersonal and Communication Skills
Required Skills
1. Create and sustain a therapeutic and ethically sound relationship with patients
a)Teaching Methods
-Role modeling
b)Evaluation Methods (Frequency and Feedback)
-Daily direct observation and feedback by attendings and program director
-Monthly MiniCEX and feedback
-Monthly formative attending evaluation and feedback
-Semi-annual program director evaluation and feedback
-360 Evaluations
2. Use effective listening skills and elicit and provide information using effective nonverbal, questioning, explanatory and writing skills
a)Teaching Methods
-Role modeling
b)Evaluation Methods (Frequency and Feedback)
-Daily direct observation and feedback by attendings and program director
-Monthly MiniCEX and feedback
-Monthly formative attending evaluation and feedback
-Semi-annual program director evaluation and feedback
-360 Evaluations
3. Work effectively with others as a member or leader of a health care team or other professional group
a)Teaching Methods
-Role modeling
-Work on the wards and clinics as member of health care team with nurses, students and medical residents
-Membership in American College of Rheumatology and Florida Society of Rheumatology
b)Evaluation Methods (Frequency and Feedback)
-Daily direct observation and feedback by attendings and program director
-Monthly MiniCEX and feedback
-Monthly formative attending evaluation and feedback
-Semi-annual program director evaluation and feedback
-360 Evaluations
Expectations for level of training
First year fellows-
A)They will be encouraged, guided and evaluated regularly in their ability to work effectively as part of the health care team.
B)Emphasis will be placed through teaching and role modeling in the creation of therapeutic and ethically sound relationships with patients in both the inpatient consultation service and the outpatient clinics.
C)Through close observation and evaluations such as the Mini-CEX we will aid the fellows in the development of effective listening skills and nonverbal, questioning, explanatory and writing skills.
Second year fellows-
A)They will be asked to serve in a leadership role within the health care team and also encouraged to participate in ACR fellow activities at a national level.
B)They will be continue to be evaluated on the skills emphasized during the first year with continued development expected.