Rheumatology Fellowship Program Goals and Mission Statement

I. Mission

The educational mission of the Division of Rheumatology Fellowship Program is to provide an atmosphere of learning and academic curiosity and to provide strong basic training in clinical rheumatology. We seek to fulfill this mission through a structured fellowship program that is characterized by educational objective-based learning experiences, effective and timely feedback to fellows, ongoing critical analysis of the program and faculty and close clinical and research mentoring to promote lifelong habits of self-study and learning. 

II. Program Goals

The goals of the Rheumatology Fellowship Program are: 

1) To prepare clinically competent physicians to deliver high quality medical care to patients with rheumatologic diseases and musculoskeletal disorders,

 2) To train physicians with the scientific and collaborative skills necessary to conduct basic or clinical research in the field of rheumatology and,

3) To promote the development of life-long self-directed learning skills to build upon their knowledge, skills and professionalism in order to practice high quality rheumatology in variety of settings.

III. Components of Clinical Competency in Rheumatology

  At the completion of the rheumatology fellowship training, the fellow should have mastered the following Competencies as they pertain to each of the specific goals of the curriculum:

1. Medical Knowledge: Acquisition of a solid understanding of the natural history, evaluation and therapy for the majority of diseases seen in the practice of rheumatology, including the uncommon and complicated diseases, as well as a comprehensive understanding of the pathophysiologic mechanisms of disease and knowledge of the basic and clinical sciences relevant to rheumatologic disorders. 
2. Patient Care: Proficiency in the clinical skills and procedures required of a rheumatology consultant and/or leader of a multidisciplinary health care team including ability to perform a comprehensive, accurate medical interview, physical examination, review of clinical data; and the ability to make excellent diagnostic and therapeutic decisions based on available evidence, sound judgment and patient preferences
3. Professionalism: Qualities of professionalism and humanistic skills at a level which serves as a model for trainees at a junior level, teach/role model responsible behavior; commitment to self-assessment; consistently consider needs of patients, families, and colleagues and willingly acknowledge errors.
4. Communication and Interpersonal Skills: Effective communication skills that will allow the fellow to perform as the health care team leader with peers and other professionals; establish highly effective humanistic and therapeutic relationships with patients and families; successfully educate and counsel patients, families and colleagues
5. Practice-Based Learning and Improvement: Willingness to incorporate feedback into improvement activities; constantly evaluate his/or her own performance; effectively use technology to manage information for patient care and self-improvement
6. Systems-Based Learning: Ability to effectively access and utilize outside  

resources; effectively use systematic approaches to reduce errors and improve patient care; enthusiastically assist in developing systems improvement.  

Assessment of Competency

Faculty base their judgment on observation of fellow¿s performance. Faculty who have direct contact with the fellows evaluate them at the end of each rotation and provide face- to- face feedback. The program director meets quarterly with the fellows to review the progress of each fellow and to provide guidance and counseling. Clinical proficiency levels correspond approximately with the first, second, and third four-month blocks of clinical experience, but individual fellows move through the levels at different rates depending on their rate of developing the relevant competencies.

The essential components of each of the competencies, methods of acquisition, and evaluation tools used in the rheumatology fellowship program to assess the trainees progress are summarized in the rheumatology curriculum matrix.

Curriculum Matrix: Core Competencies and Outcomes Assessment

IV. Progressive Responsibility for Patient Management

While fellows are gradually given more responsibility as they progress through the program, at all times final responsibility for the case rests with the faculty. All reports must carry an attending name and electronic signature, which signifies that the attending has verified the findings and assessment. The Program Director ensures, directs and documents adequate supervision of fellows at all times. Fellows are supervised by teaching staff in such a way that the fellows assume progressively increasing responsibility according to their level of education, ability, and experience. On-call schedules for teaching staff are structured to ensure that supervision is readily available to fellows on duty.

Fellows evaluate the patient and present each case to the attending physician throughout the 2 years of their fellowship. As they progress, fellows are given more responsibility. In the ambulatory setting, they continue to check out all patients with the attending, but give a full presentation only of problem cases as their competency increases.

V. Methodology for Teaching Rheumatology to the Fellows

 In order to achieve the goals and objectives for the fellowship program the following experiences have been established for the purpose of teaching Rheumatology fellows. These include: A) Inpatient Consultation experience, B) Rheumatology Ambulatory Consultation experience, C) Ambulatory rotations with other clinical subspecialties,

D) Formal instruction in small group didactic conferences, seminars and tutorials, E) Research experience F) Continuing medical education and society participation, and G) development of teaching skills.

The Inpatient Rheumatology Experience

Objectives

Fellows will develop the knowledge base and clinical skills necessary to develop optimal care of the most complex and highest risk hospitalized patients with rheumatologic disorders. These skills include: development of an appropriate differential diagnosis, assessing the need for hospitalization, formulation of diagnostic evaluation strategies and treatment plans. Another key aspect of the inpatient experience is the development of skills in providing consultation services including the drafting of a pertinent consultation note, communicating with the referring physician and obtaining family and community support for ongoing care.

Educational process

  Knowledge and experience are communicated from the faculty to the fellow in the form of daily patient rounds, conferences, didactic sessions, bedside training in the performance of the physical examination, history taking, chart review, note writing, procedures, synovial fluid analysis and polarized microscopy, laboratory test result interpretation and effective communication with the patient, nursing staff, support staff and other physician. Fellows will have the opportunity to directly review biopsy (e.g., skin, kidney) results with Pathology staff and to develop a rudimentary knowledge of biopsy interpretation. Fellows will also be expected to directly review interesting and challenging imaging results with Radiology staff, and to communicate that information with the Rheumatology consult and inpatient teams.

  The fellow will be called upon to perform literature research on topics appropriate to the case at hand and share this knowledge with the ward house staff and inpatient consultation team. The fellow is responsible for actively participating in the teaching activities of the inpatient consultation team including supervision of resident and medical students rotating on the Rheumatology service.  The fellow will be responsible for presenting cases at the weekly formal bedside teaching rounds.

  The hospitalized patient populations at each training site provide the opportunity for the fellow to expand his/or her knowledge base about the most critical and complex aspects of rheumatologic disorders and musculoskeletal complication of serious medical and surgical illnesses.   Through this experience the fellow will develop a comprehensive understanding of the indications, contraindications, techniques, and complications of arthrocentesis as well as the interpretation of results from procedures.  The fellow will acquire the skills necessary to educate patients about diagnostic tests and obtain informed consent.   The case mix varies somewhat at the different hospitals: At FUMC a higher percentage of inpatients have systemic lupus erythematosus, severe pulmonary hypertension complicating systemic connective tissue disease, septic and other complications of bone marrow liver, lung, heart and pancreas transplantation surgery. At the VAMC the case mix is skewed toward systemic vasculitis, surgical and medical complications of rheumatoid arthritis and spondyloarthropathies, septic arthritis, and rheumatologic complications of chemotherapy, cardiovascular surgery and orthopedic surgery. At HCMC, the case mix favors: systemic lupus erythematosus, including among younger minority patients with severe nephritis; rheumatic complications of hemodialysis and renal transplantation; complications of HIV infection; complications of hepatitis C; crystal-induced arthritis; and metabolic bone disease.

The Ambulatory Rheumatology Experience

Objectives

Fellows will develop expertise in the outpatient evaluation and management of patients with rheumatologic and musculoskeletal problems and become skilled in the assessment of disease activity, therapeutic response and interpretation of diagnostic tests.  The experience will provide the opportunity to develop knowledge about the natural history of these disorders over a prolonged period of time.

Staffing

All rheumatology clinic sessions are coordinated and supervised by rheumatology faculty.

            Educational Process

The practice of rheumatology is predominantly outpatient. Therefore, the ambulatory experience during the rheumatology fellowship is mandatory and extensive in breadth, depth and oversight.  All fellows are required to maintain the equivalent of 2 half-day rheumatology clinic sessions averaged over the 2 years including two half-day clinics during the research time. Fellows maintain a continuity clinic throughout their fellowship. During the ambulatory clinic sessions, the fellow will learn to interact with other members of the health care team. They also acquire experience and develop competency in procedural skills including: joint aspiration; and joint, tendon and bursa injections, monitoring of patients on anti-rheumatic drugs including NSAIDs and DMARDs, and provision of outpatient IV therapies. The fellow will have opportunities to perform joint, bursa, and soft tissue procedures under the supervision of rheumatology faculty; and to develop proficiency at synovial fluid and crystal analysis. There are also opportunities to personally examine urinary sediment for patients with active glomerular disease.

Optionally, as time and interest permit, the fellow will have an opportunity to participate in the development of customized tools in the HCMC electronic health records (EHR) system for Rheumatology Clinic, to assist in quality management and communication with other providers.

Orthopedics Ambulatory Experience

Objectives:

Emphasis is on learning exam skills for diagnosis of orthopedic problems and proficiency in interpretation of radiographs.  Rheumatology fellows are expected to demonstrate competency in the evaluation of patients with ambulatory orthopedic problems, knowledge of surgical indications and complications, and skill in interpretation of imaging studies. 

Educational Process:

The ambulatory orthopedics rotation is scheduled during the second half of the first year. Rheumatology fellows attend 2 clinics per week over 4 weeks in the following subspecialty areas:  Knee and Hip Reconstruction, Ankle and Foot, Hand/Wrist, Shoulder, Sports Medicine. The patient-mix includes individuals with sports and athletic-related problems, arthritis, fractures, and non-sports related trauma as well as metabolic bone disorders. Fellows participate in specialty clinics and assist in the evaluation of patients being evaluated for arthroplasty, tumors and infections. All patients are evaluated in conjunction with staff. In most cases, the supervision is one-to-one with only one trainee assigned to work in each clinic. Fellows are expected to participate in orthopedic teaching rounds and conferences when appropriate. On occasion they will participate in the pre and post operative care of patients undergoing joint reconstruction and observe the operative cases performed on those same patients to gain first hand experience.

A. Fairview University Medical Center clinics-

1. Rheumatology Clinics: Fellows attend 1-2 general rheumatology clinics/week. Five fulltime rheumatologists staff the clinics.  The patient mix differs from the MVAMC with a higher percentage of patients with systemic lupus, systemic vasculitis, fibromyalgia, organ transplant related arthropathies, and autoimmune disease of the eye and ear.
2. Pediatric Rheumatology Clinic: The fellow participates in the Pediatric Rheumatology Clinic weekly with Dr. Richard Vehe. (Ambulatory Rotation 5 or 6 in the second year.) It is here that they gain their experience in the field of pediatric rheumatology, including knowledge about the disorders and the clinical manifestations that arise in children, the treatment modalities and the drug dosages employed in the pediatric age group.
3. Osteoporosis Program: The fellow learns how to evaluate patients referred for bone disease particularly osteoporosis secondary to drugs or metabolic disease.  A major focus of this learning experience is how to provide interpretation of scan results in a specific clinical context and to select appropriate treatment recommendations.
4. FUMC Continuity Clinic: The fellows maintain one half-day continuity clinic per week at FUMC throughout the two years of clinical training. They follow a broad mix of patients with complicated rheumatic diseased referred for rheumatologic consultation from a region that includes the entire Upper Midwest. Those disorders frequently encountered included the systemic connective tissue disorders, autoimmune diseases of the ear and eye, rheumatic syndromes frequently encountered in the young adult population and fibromyalgia. Full-time faculty rotate the responsibility of staffing the fellows Continuity Clinic insuring that the fellows are exposed to a variety of teaching and patient care approaches. Fellows have progressive responsibility for case management as their rheumatology knowledge base and clinic skills develop.

B. Minneapolis VAMC Clinics

1. Rheumatology Clinics: The fellows attend one-two half-day clinic session in which they evaluate patients with a variety of rheumatologic diseases. Three rheumatology faculty and one private practice rheumatologist who provide a variety of approaches to the practice of rheumatology staff these clinics.
2. Continuity Clinic: At the VAMC, fellows will develop familiarity with the epidemiology, pathogenesis, diagnosis and prevention and treatment of rheumatic diseases frequently encountered in the VAMC patient population especially Rheumatoid arthritis, Spondyloarthropathies, Osteoarthritis, Crystalline disorders, HCV related rheumatic problems, rheumatic disorders encountered in the elderly, regional pain problems, and vasculitis.

C. Hennepin County Medical Center

          1. Rheumatology Clinics: Fellows attend 1-2 half-day general rheumatology clinics per week. These clinics are staffed by one full-time and 2 part-time rheumatologists. The clinic staff also includes 2 principal, and several back-up, nurses. There is a fairly wide case mix, depending on the referral source (ED, inpatient discharge, self-referral, referral from primary care, etc.). For those patients who have need for ongoing rheumatology subspecialty care, a cooperative plan of care will be developed between the rheumatologist, primary care provider, and other specialists when needed. High priority is placed on developing effective communication skills between the Rheumatology Clinic and primary care provider, both within and outside HCMC.

         2. Continuity Clinic: The fellow will maintain a continuity clinic for one half-day per week throughout the two years of clinical training. Patient selection will be monitored carefully to ensure a diverse case mix. This will include the opportunity to choose patients who were initially encountered on the inpatient consultation service. The fellow will also see patients for initial rheumatology evaluations. 

D. Regions Hospital

E. Didactic Conferences, Seminars, and Tutorials

Fellows participate in the Basic Science, Clinical Science and Core Curriculum didactic sessions.  Attendance is required of the fellows and includes, on a rotating basis, at least one faculty preceptor who prepares and distributes study guide questions, provides critical appraisal of relevant information in the current literature, and leads the discussion. Fellows are expected to read the relevant chapters assigned either in: Kelly¿s Textbook of Rheumatology or in Abbas¿ text: Cellular and Molecular Immunology. The format is that of a small group seminar in which each fellow shares in the responsibility of reviewing the material. Basic Science and Clinical Science Didactics take place in alternate weeks throughout the two years of the fellowship. Clinical and basic science topics are covered in a 45-minute session back to back (alternating weekly with a one an one/half hour session devoted to review of basic principles of immunology.)

 Fellows present cases and report on pertinent information from a review of the literature during the weekly teaching rounds. The two fellows share responsibility for preparing the Clinical Conference and Journal Club. Each month the fellow either prepares a journal article or a case presentation for the City-Wide Conference.

City-Wide Rheumatology Clinical Conference held monthly.  Fellows are expected to gather, organize and communicate the clinical data; utilize current clinical literature for patient management; and participate in the discussion of the clinical problem.

City-Wide Rheumatology Journal Club: held monthly. Fellows are responsible for selecting and discussing important articles in the recent literature. They are expected to be able to evaluate study design, results and conclusions.

Fellows are also expected to attend and participate in the City-Wide Rheumatology Research Conference that is held monthly. At least once each year, the fellow will describe their own investigative project and discuss the experimental methods utilized, data collection and conclusions.

The City-Wide Radiology/Multidisciplinary Conference: held monthly according to a case-based format. For this conference, fellows are expected to be able to identify characteristic radiographic findings/biopsy results or unusual presentations of various rheumatic diseases and develop a differential diagnosis. The discussion leader is a member of the radiology, orthopedic or rheumatology faculty. Fellows are expected to assist in gathering cases for review and to review the pertinent clinical features of each group of disorders in advance of the conference.

Attendance at the City-Wide conferences is required of all fellows and division faculty.

Case of the Week Rounds is a one-hour conference attended by the program director and other faculty, the residents, students and the rheumatology fellow assigned to the FUMC clinical rotation. The responsibility of the fellow is to present a case for discussion and to be able to teach students and residents about clinical features, laboratory abnormalities and physical findings of the rheumatic disorders.

Morbidity and Mortality Conference: held weekly at both hospitals. The educational objective is to review diagnostic or therapeutic errors for quality assurance.  Fellows are expected to be able to evaluate and improve their own clinical knowledge and diagnostic and treatment skills.

Program Directors Feedback Club: This is an informal session designed to encourage an uninhibited exchange of ideas.  The meeting is held every two months. Participants are the fellows and the program director. Fellows provide feedback to the program director regarding the training program, discuss clinical and research learning issues, develop methods to solve problems in a timely manner and individualize the program to each fellow¿s educational needs.

Other conferences which fellows are required to attend include:

Core Curriculum for Graduate Medical Education: The topics covered are diverse including areas related to professional ethics, cost containment, medical/legal issues, health care delivery systems, and preventive medicine as well as topics relating to critical appraisal of the medical literature and principles of medical statistics. (See GMEC schedule for 2007-2008)

Fellows are encouraged to select from and attend according to their interests the following conferences:

Immunology Data Club:  weekly one-hour conference held at FUMC. Fellows will be able to gather, organize and evaluate scientific data; utilize statistical methods in the interpretation of data and participate in evaluation of experimental data.

Immunology Journal Club:  weekly one hour conference held at FUMC. Fellows will demonstrate ability to critique a basic science article and to discuss basic science immunology topics relevant to the rheumatic diseases and investigations

Orthopedic Core Curriculum Conferences: small group sessions taught by orthopedic attendings. Conference held weekly for one and one/half hours. Orthopedic trainees are required and rheumatology fellows are invited to attend.

Medicine Research Conference: Held at both the FUMC and VAMC weekly. Fellows will be able to evaluate experimental methods, data and conclusions and to describe their own investigations.

F. Participation of Fellows in Research

An appropriate, focused and productive research experience for each fellow is a primary goal of the rheumatology fellowship.  The intensity and depth of research training is tailored to meet the needs of individual fellows. Second year fellows interested in pursing a basic science career are expected to devote a majority of their time to bench research supervised by their faculty mentor. Fellows interested in pursuing an academic career with a focus in clinical research are encouraged to pursue training in clinical research and design leading to a master¿s degree in the school of public health. A 3^rd year of fellowship training devoted to research is strongly advised for all fellows interested in an academic rheumatology career.

Each fellow is expected to discuss his/her interests and research options with faculty members individually and with the Division Director and Rheumatology Committee Research Chair before making a commitment to a particular project or mentor early in the first quarter of the first year. Incoming fellows will be expected to choose between a lab based research focus or clinical research.

During the first year of the program, each fellow identifies a research mentor who will be responsible for helping the fellow plan and carry out the project as well as assisting with future career planning.  In addition, fellows discuss their research with the Program Director prior to the initiation of the project and quarterly, thereafter, to discuss the content and progress of the project. The research committee must formally approve both the initial research plan (before data collection begins) and the final research project. Fellows also receive constructive criticism of their research during their presentation at a Research Conference.  Fellows, in coordination with the primary mentor, are responsible for seeking Human Subjects Committee and other required approvals before beginning work on the their project. They meet regularly with the preceptor to ensure data collection is on target, review first draft of abstract, and when data collection is complete submit to national and/or regional meetings.

Second year fellows submit IRB applications if projects require one, and submit an application for funding if financial assistance is required. During the second year, fellows will have a minimum of the equivalent of two dedicated months for completion of their research project. Fellows are expected to submit at least one abstract to a local, regional or national scientific meeting and one manuscript for publication based on work performed during their training.

G. Continuing medical education and society memberships

All fellows are strongly encouraged to become members of the American College of Rheumatology and the Minnesota Chapter of the Arthritis Foundation.  Fellows are encouraged to participate in the continuing medical education activities of these professional organizations to help foster the standards of professionalism and augment the process of lifelong learning. 

 Fellows will attend the Central Society for Clinical Research Meeting or the national meeting of the American College of Rheumatology and be encouraged to present research data there.

H. Experience in developing teaching skills

The program fosters and highly regards the activities of teaching by the fellows. This includes the education of not only medical students, physicians, and other allied health personnel but also the education of the patients. Fellows are respons