Curriculum‎ > ‎Electives‎ > ‎Rheumatology‎ > ‎

Goals and Objectives

Revised 2011, 2014 

ALBERT EINSTEIN COLLEGE OF MEDICINE

MONTEFIORE MEDICAL CENTER 

INTERNAL MEDICINE RESIDENCY PROGRAM

ROTATION: RHEUMATOLOGY ELECTIVE

I. Goals and Objectives::

A. Goals:

The rheumatology elective is designed to equip residents with the clinical skills needed to recognize and manage common rheumatic diseases. It is well known that early diagnosis and treatment of rheumatic conditions improves patient outcomes and reduces the medical and social impact of these diseases (1). By exposing residents to rheumatology in both the inpatient and outpatient settings, a complete understanding of these disease processes is fostered. Residents are encouraged to appreciate the individual and multispecialty approaches to caring for rheumatology patients. The elective also combines direct patient care with basic science seminars and an understanding of the pathogenesis of arthritis, metabolic bone disease and autoimmunity. At the end of the rotation the resident can expect to be comfortable with the diagnosis, investigation and management of common rheumatic diseases and the recognition of less common syndromes thus facilitating their prompt referral for specialized care.

The rheumatology elective is a one block rotation (of approximately 2 or 4 weeks duration) and involves participation in the in-patient rheumatology consultation service, two weekly out-patient arthritis clinic sessions, one weekly out-patient systemic lupus erythematosus (SLE) clinic session, two weekly journal clubs and one rheumatology seminar/grand round conference.

The rheumatology elective is available to all Internal Medicine residents.

PGY Level 1, 2, 3 Competency Based Objectives:

The residents will function as members of the Consult Team, as such their level of independence and responsibility given will be PGY year dependent.  However, all members of the team are expected to demonstrate competency in the following areas:

Patient Care: Prioritize the day’s work schedule; recognize the relative significance of a given patients rheumatologic conditions; begin to recognize acuity of illness; understand the indications, contraindications, and risk of common procedures used in the specialty; work with all providers to extend quality care at all times; supervise the junior staff in patient care, including rotating medical students.

-          Medical Knowledge: Use literature and reference sources to increase knowledge base; demonstrate basic knowledge in the areas of underlying pathophysiology of connective tissue, and the clinical aspects of common and/or organ/life threatening rheumatologic diseases; apply knowledge in the treatment of patients

-          Professionalism:  Establish trust with patients, other caregivers and staff; exhibit honesty, reliability and responsibility in patient care; demonstrate respect for patients and all staff including ancillary personnel; work to fulfill the needs of patients; accept assignments graciously; attend divisional conferences; respond promptly to consultation requests 

-          Interpersonal Skills:  Write understandable and timely notes; develop the ability to listen to patients, families, staff and ancillary personnel; communicate verbally and nonverbally in a productive and constructive manner; work effectively as a member of the health care team

-          Practice Based Learning and Improvement: Recognize accept the limitations of ones knowledge and use that as an opportunity for personal growth; use references and literature (including computer based resources) in professional communication and to improve practice patterns; accept feedback willingly and change behavior appropriately; ask for help when needed

-          Systems Based Practice: Be the patients’ advocate; learn about health care system and structure (locally/regionally); begin to develop mechanisms to utilize ancillary services to benefit patients

II. AREAS COVERED DURING ROTATION:

1.      Pathophysiology and Basic Sciences of the Rheumatic Diseases and Immunology:

Residents develop an understanding of the pathogenesis of rheumatic disease through direct one on one interaction with teaching staff and through exposure at divisional conferences, becoming familiar with:

a) The pathogenesis of rheumatoid arthritis
b) The pathgenesis of autoimmunity
c) Understanding Connective Tissue Diseases
d) Understanding Metabolic Bone Disease
e) Understanding osteoarthritis

                  2.   Practice skills unique to Rheumatology:

a) The history and physical examination in the rheumatology patient: differentiating localized pathology from systemic disease and understanding the signs and symptoms of inflammation as distinct from the biology of metabolic and degenerative diseases.
b) Explain the usefulness of investigations for rheumatic disease including antibody profiles in autoimmune diseases; the use of the sedimentation rate, C-Reactive protein and other acute phase reactants in diagnosing inflammatory rheumatic diseases.
c) Identify the utility of specific tests for rheumatic disease and their appropriate use as diagnostic and prognostic markers; e.g. the anti-CCP antibody in rheumatoid arthritis.
d) Describe the use of Disease Assessment Tools in monitoring patient’s disease activity indices, response to treatment, and also for when treatments fail and need to be adjusted.
e) Appreciate the importance of patient compliance in treating rheumatic diseases including gout, rheumatoid arthritis, systemic lupus erythematosus and osteoporosis.
f) Develop an understanding of the medical, economic and social costs of rheumatic diseases both to the individual and to society at large and appreciating the importance of early and optimal intervention.
g) Explain the significance of arthrocentesis, soft tissue and joint injections.

3.      Approach to common presenting complaints/problems in Rheumatology:

                                a)    Acute arthritis

i) Acute monoarthritis
ii) Acute oligoarthritis
iii) Acute polyarthritis

                                b)   Chronic Arthritis

i)             Chronic monoarthritis

ii)            Chronic oligoarthritis

iii)           Chronic polyarthritis

c)        Rash with arthritis

d)       Myopathy with arthritis

e)        CNS disease and Neuropathy with arthritis

f)         Postinfectious arthritis syndromes including HIV

g)        Gastroenteric complaints and rheumatology

h)        Renal disease in rheumatology

i)             Nephritis

ii)            Nephrosis

i)          The eye in rheumatic disease

j)          Rheumatic complaints without frank arthritis

k)        Pregnancy and rheumatic disease

l)          The pediatric rheumatology patient

4.      Specific Diagnoses in Rheumatology

a) Inflammatory polyarthritis, eg: Rheumatoid and Psoriatic 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 muskuloskeletal pain syndromes
j) Nonarticular rheumatic diseases, including fibromyalgia
k) Postinfectious arthritis
l) Nonsurgical, exercise-related (sports) injury
m) Soft tissue arthritis
n) Systemic diseases with rheumatic manifestations
o) Rheumatic manifestations of malignant diseases
p) Osteoporosis
q) Infections of joints, bones and soft tissues
r) Sjogren’s syndrome, overlap syndromes and mixed connective tissue disease
s) The rheumatic manifestations of autoimmune thyroiditis and autoimmune liver disease
t) Pediatric rheumatic conditions
u) The psychological impact of rheumatic diseases and chronic pain syndromes

                 5.  Emergencies/Therapeutic Interventions:

a) Severe lupus nephritis
b) Severe thrombocytopenia and thrombotic thrombocytopenic purpura in the lupus patient
c) Lupus cerebritis and transverse myelitis
d) Life threatening lupus pneumonitis
e) Giant cell arteritis with visual loss and CNS involvement
f) Conservation of renal function in scleroderma renal crisis
i) Prompt ACEI use, BP control
g) Life-threatening vasculitis
h) Septic Arthritis 

                 6)   Technical Skills:

a) Joint and muskuloskeletal examination
b) Joint aspiration and injections
c) Soft tissue injections
d) Microscopic examination of aspirated or expressed crystal material and other pathological specimens
i) Light microscopy
ii) Polarized light microscopy
iii) Fluorescence microscopy
e) Interpretation of Radiographs and Bone densitometry data
f) Urinalysis
g) Fundoscopic examination and nailfold capillaroscopy
h) Interpretation of laboratory data including autoantibody profiles and genomic and proteomic analysis; e.g. IF, ELISA and Western blot interpretation
i) Understanding the genetic evaluation of heritable rheumatic conditions; e.g. FMF, other periodic feveres and amyloidosis 

III. SCHEDULE OF ACTIVITIES

 

 

Monday

Tuesday

Wednesday

Thursday

Friday

 

 

 

 

 

 

AM

Ward

Lupus Clinic

Journal Club

Ward/ Clinic- JMC

Grand Rounds

Arthritis Clinic

PM

Ward

Ward

Ward

Ward

Arthritis Clinic

 

IV. REFERENCES

Residents on elective will obtain access to the Division of Rheumatology online article collection

 

 

 

 

 

 

 

 

 

 

 

 

V. Methods of Evaluation and Assessment

The house officer is evaluated continuously during their weeks of service on the Rheumatology elective. Importantly, formative feedback is given to the rotating house officer throughout the rotation experience. The final evaluation is entered through www.new-innov.com and a summary performance assessment is discussed in a meeting with the house officer. This evaluation will assess overall clinical competence as reflected by the following subcategories: patient care, medical knowledge, clinical skills, humanistic qualities, professionalism, lifelong learning and systems-based practice.

 

 

 

Arthritis Clinic Rotation at Montefiore Medical Center and

Jacobi Medical Center

Competency based curriculum

(adapted from American College of Rhematology)

 

 

The competencies are abbreviated as follows:

PC – Patient care

MK – Medical knowledge

PL – Practice-based learning and improvement

ICS – Interpersonal and communication skills

PF – Professionalism

SP – Systems-based practice

 

Arthritis Clinic

The Goals and Objectives of the Arthritis Clinic rotation are:

1. To allow trainees to enhance their medical knowledge of the pathophysiology, clinical features, diagnosis and management of rheumatoid arthritis, spondyloarthropathies, osteoarthritis, osteoporosis, fibromyalgia, vasculitis, inflammatory muscle disease, scleroderma, 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

these conditions 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 joint deformity and radiographic progression of arthritis, avascular necrosis, pulmonary complications of rheumatic diseases, 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 and to demonstrate understanding of the impact of cultural differences in the management of the disease. (ICS)

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 patients and the practice of evidence-based cost effective care. Particular  attention is paid to the indications, cost implications and prior approvals necessary for the use of biologics (SP)

6. To develop practice-based learning skills in the trainees to help deal with the

complicated diagnostic and therapeutic challenges these patients present. (PL)

7. To involve trainees in ongoing research studies in the autoimmune diseases, including laboratory studies of aberrant immune function, clinical outcome studies including therapeutic infusion studies with new and established biological agents, research ethics, and the consent process. (MK, PF)

8.  To develop competency in all aspects of joint aspiration and injection including indications, contraindications and complications of these procedures.  For the residents, emphasis will be placed on developing competency in aspiration and injection of the knee. Other joints include, but are not limited to aspiration and /or injection of all major, intermediate and small joints, injection of tendon sheaths and bursae and trigger point injections.  (MK, PC)

9.  To develop competency in appropriate interactions with other professionals involved in the treatment of patients with arthritis and autoimmune disease including but not ;imited to physiatry, occupational therapy, orthopedics and neurology.  There is a physiatrist in the clinic regularly and the residents have the opportunity to learn from them the indications, benefits and limitations of physical and occupational therapy. (MK, PC, ICS, PF)

10.  For the residents to learn the indications, benefits and limitations of various orthopedic procedures through didactic teaching and interaction with the orthopedic surgeons on various cases. (MK, ICS)

 

Descriptive:

There are numerous rheumatology textbooks available in hard copy in the clinic and there is computer access to UpToDate online as well as the Albert Einstein College of Medicine library online in the clinic.  (MK)

The residents attend radiology conference on a monthly basis and have the opportunity to review X-rays both on film and online through the hospital’s EMR radiology system to develop proficiency in recognizing the various radiographic appearances of degenerative and inflammatory arthropathies and have the opportunity to follow X-ray changes over time. (MK,PC)

The residents have to address complicated and patient management issues and must participate in decisions about admission of acutely ill patients to the hospital (PC, MK, SP). When necessary, these patients are followed by the Rheumatology Teaching Service, and inpatient management is coordinated and supervised by the consult fellow who works with and teaches the medical housestaff team (PC, PL, ICS, PF).

Multiple health care providers must be called upon to assist in the management of these patients; this includes nursing, radiology, dermatology, pulmonary, ophthalmology, nephrology, neurology, social work, orthopedics and physical therapy (PC, ICS, PF, SP).

Some patients speak English poorly and an interpreter is required (ICS, 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, ICS, SP). Some patients are nonadherent to their medical regimens for social or financial reasons and alternative approaches to their management may be needed (ICS, PF, SB).

Clinic visits address comorbid illnesses, such as diabetes and hypertension, and side effects of therapy (PC, MK, PL).

A weekly journal club prior to clinic has fellows and attendings review a journal article pertaining to the rheumatic diseases and present this to their peers and attendings. (MK, ICS, PF) Research studies are being conducted in this

population and the residents are invited to participate in identifying appropriate patients (MK, ICS, PL).

 

 

Core Competency Acquisition in the Arthritis Clinic(s)

 

COMPETENCY                                                                                           ACTIVITY

 

 

SCE    DID     SDL   DEM

Patient care (PC)                                                                   Yes      Yes      Yes      Yes

 

Medical knowledge (MK)                                                     Yes      Yes      Yes      Yes

 

Practice-based learning and

improvement (PL)                                                                 Yes      Yes      Yes

 

Interpersonal and

communication skills (ICS)                                                   Yes

 

Professionalism (PF)                                                             Yes      Yes      Yes

 

Systems-based practice (SB)                                                 Yes      Yes      Yes (QI)

 

Activity Abbreviations

SCE – supervised clinical experience

DID – didactics – case conferences, lectures, meetings

SDL – self directed learning

DEM – demonstrations, e.g. joint injection, infusion of biologics


 

Lupus Clinic Rotation at Montefiore Medical Center

 

Competency based curriculum

(adapted from American College of Rhematology)

 

 

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 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 recognize how to diagnose and manage disease flares, infection and

other comorbid illnesses and the side effects of medications. (PC)

3. To introduce trainees to diagnosis and prevention of 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 and to demonstrate understanding of the impact of cultural difference in the management of the disease. (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 enhance awareness for the of ongoing research studies in SLE (MK, PF)

 

 

 

Description:

An electronic medical record (EMR) used for all ambulatory patients is being utilized in this clinic;

The residents have to address complicated patient management issues and must participate in decisions about admission of acutely ill lupus patients to the hospital (PC, MK, SP). When necessary, these lupus patients are followed by 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).

Residents are encouraged to research the literature about diagnostic and

therapeutic problems related to these complicated patients (PC, MK, PL). Research studies are being conducted in this population and the residents are invited to participate in identifying appropriate patients, (MK, IC, PL).

 

 

Core Competency Acquisition in the Lupus Clinic

 

 

COMPETENCY                                                                                           ACTIVITY

 

 

 

SCE    DID     SDL   DEM

Patient care (PC)                                                                   Yes      Yes      Yes     

 

Medical knowledge (MK)                                                     Yes      Yes      Yes      Yes

 

Practice-based learning and

improvement (PL)                                                                 Yes      Yes      Yes

 

Interpersonal and

communication skills (IC)                                                     Yes

 

Professionalism (PF)                                                             Yes      Yes      Yes

 

Systems-based practice (SB)                                                 Yes      Yes     

 

Activity Abbreviations

SCE – supervised clinical experience

DID – didactics – case conferences, lectures, meetings

SDL – self directed learning

DEM – demonstrations, e.g. joint injection, infusion of biologics

 

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