Rheumatology

Department: Internal Medicine

Periods offered: All

Length: 4 weeks

Max no. of residents: 2

First Day Contact: Stanley Cohen, MD (214) 540-0700 or page through operator at (214) 345-8480

First Day Time: 8:30 am

First Day Place: Rheumatology Associates, 8144 Walnut Hill Lane, Suite 800, Dallas, TX

Requirements: 8:30 am to 5:00 pm ­ Monday thru Friday

Weekends: None

I.  Course Description:

Referral based rheumatology outpatient practice which will expose residents to the presentation, evaluation and treatment of the patient with rheumatolocial disease. Residents will also be responsible for consultation, evaluation and management of in-patients with rheumatological disease.

II.Course Goals and Objectives: (based on ACGME competencies for resident education)

Patient Care:

Residents are expected to provide care that is compassionate, appropriate and effective for the promotion of health, prevention of illness, treatment of disease and at the end of life.

Objectives:

• Gather accurate, essential information from all sources, including medical interviews, physical examinations, medical records and diagnostic/therapeutic procedures. Examples: Resident will perform an accurate rheumatological history and physical and appropriately order tests to evaluate the disease state. Resident will be skilled at large joint arthrocentesis.

• Make informed recommendations about preventive, diagnostic and therapeutic options and interventions that are based on clinical judgement, scientific evidence, and patient preference. Examples: Resident will know how to interpret a positive ANA, Rheumatoid factor and CCP antibodies. Resident will know appropriate lab tests to order to approach a patient with a possible rheumatological disease. Resident will understand the risk/benefit of therapeutic options.

• Develop, negotiate and implement effective patient management plans and integration of patient care. Examples: In a patient with DJD, when to refer for surgical treatment; use of physical therapy/occupational therapy in treatment of RA patient.

• Perform competently the diagnostic and therapeutic procedures considered essential to the practice of internal medicine. Examples: X-ray of neck on patients with RA going for surgery. Know how to monitor the toxicity of common immunosuppressive agents used to treat patients with rheumatological diseases.

Medical Knowledge:

Objectives:

• Apply an open-minded, analytical approach to acquiring new knowledge. Examples: Resident will present in an orgranized fashion using evidence based medicine a clinically relevant question every week.

• Access and critically evaluate current medical information and scientific evidence. Examples: Resident will use electronic medical information system to obtain medical information and know how to interpret the scientific evidence.

• Develop clinically applicable knowledge of the basic and clinical sciences that underlie the practice of internal medicine. Examples: Resident will understand the mechanism of action of immunosuppressive medications used to treat common rheumatologic conditions. The resident will apply basic immunology concepts to patient care through medication counseling, and decision making.

• Apply this knowledge to clinical problem-solving, clinical decision-making, and critical thinking. Examples: Recognize the significance of fever in a patient with lupus. Recognize the utility of ANA testing, and the need for referral to Rheumatology. Recognize the importance of infection inlcuding opportunistic infections in immunosuppressed patients.

Practice-Based Learning and Improvement:

Objectives:

• Identify areas for improvement and implement strategies to enhance knowledge, skills, attitudes and processes of care. Examples: Set up a process to assure pneumococcal and influenza vaccinations in the immunocompromised patient.

•  Analyze and evaluate practice experiences and implement strategies to continually improve the quality of patient practice. Examples: Review charts for up to date lab monitoring in patients on immunosuppressives.
  
  
• Develop and maintain a willingness to learn from errors and use errors to improve the system or processes of care. Examples: Review charts to verify that all patients in biological treatment for RA have screened for TB.

• Use information technology or other available methodologies to access and manage information, support patient care decisions and enhance both patient and physician education. Example: Evaluate cardiovascular risk of patients with osteoarthritis before prescribing COX-2 inhibitors and traditional NSAID's.

Interpersonal and Communication Skills:

Residents are expected to demonstrate interpersonal and communication skills that enable them to establish and maintain professional relationships with patients, families and other members of health care teams.

Objectives:

• Provide effective and professional consultation to other physicians and health care professionals and sustain therapeutic and ethically sound professional relationships with patients, their families, and colleagues. Examples: Discuss with a patient risks and benefits of DMARD use. Discuss with a newly diagnosed lupus patient the natural history of the disease.

• Use effective listening, nonverbal, questioning, and narrative skills to communicate the patients. Examples: Explain to a patient the community resources and support groups available for his/her specific disease.

• Interact with consultants in a respectful, appropriate manner. Examples: Discuss with an orthopedic consultant the DVT prophylaxis per knee replacement.

• Maintain comprehensive, timely, and legible medical records. Examples: Use electronic medical records in clinic.

Professionalism:

Residents are expected to demonstrate behaviors that reflect a commitment to continuous professional development, ethical practice, an understanding and sensitivity to diversity and a responsible attitude toward their patients, their profession, and society.

Objectives:

• Demonstrate respect, compassion, integrity, and altruism in relationships with patients, families, and colleagues. Example: We expect residents to arrive on time to clinic, be proactive and to be respectful in the assessment of their patients.

• Demonstrate sensitivity and responsiveness to the gender, age, culture, religion, sexual preference, socioeconomic status, beliefs, behaviors and disabilities of patients and professional colleagues. Example: Obtain a complete social history that includes martial status, travel history, and preferred language.

• Adhere to principles of confidentiality, scientific/academic integrity, and informed consent. Examples: Discuss the document in the charts, risks and benefits before an arthrocentesis.

• Recognize and identify deficiencies in peer performance. Examples: In a positive way, discuss improvements in the clinic systems to optimize patient care.
  

Systems-Based Practice:

Residents are expected to demonstrate both an understanding of the contexts and systems in which health care is provided, and the ability to apply this knowledge to improve and optimize health care.

Objectives:

• Understand, access and utilize the resources, providers and systems necessary to provide optimal care. Examples: PT/OT nurse educators on patients with RA.

• Understand the limitations and opportunities inherent in various practice types and delivery systems, and develop strategies to optimize care for the individual patient. Examples: Rheumatology involves the care of patients with multisystem diseases, coordinating the patient care through appropriate consultations can improve their care. Ensuring adequate screening for tuberculosis in patients taking biologics and updating their immunizations will improve their care.

• Apply evidence-based, cost-conscious strategies to prevention, diagnosis, and disease management. Examples: Evaluate a patient with rheumatoid arthritis, and identify the need for biologic therapy. Evaluate patients taking corticosteroids, counseled them about adequate calcium, vitamin D intake, weight bearing exercises and the need for DXA testing.

• Collaborate with other members of the health care team to assist patients in dealing effectively with complex systems and to improve systematic processes of care. Examples: Residents should be able to recognize the need for consultations from other specialties and other health care professionals such as PT, OT, psychologist, etc.

A. Didactic (schedule, topic, faculty)

Rheumatology:
During the four week rotation the following topics will be covered:
- Rheumatoid arthritis
- Systemic lupus erythematosus
- Spondyloarthritis
- Systemic Sclerosis
- Inflammatory myopathies
- Small vessel vasculitis
- Polymyalgia rheumatica and giant cell arteritis
- Osteoarthritis
- Fibromyalgia
- Osteoporosis
- DMARD therapy
- Crystal arthropathy
- Laboratories in rheumatology

Internal Medicine
Daily residents conference 12:00-1:00 p.m. - IM Training Room
Wednesday mornings 7:30-8:00 a.m. - Clinical Ground Rounds - IM Training Room
Wednesday afternoons 12:15-1:00 p.m. - Internal Medicine Update - Haggar Hall

B. Clinical

Evaluate and treat patients with rheumatological diseases in the outpatient setting. Performing histories and physicals. Formulate and carry out a diagnostic differential and therapeutic plan and communicating that plan verbally and/or in writing to the patient, the supporting medical team and the consulting physician.