Revised February 18, 2008
GOALS AND OBJECTIVES
RESIDENT CURRICULUM FOR RHEUMOTOLOGY
UMC AND SUBSPECIALTY CLINIC
Rotation Coordinator:
Kenneth Grant, MD
Professor of Medicine
Department of Internal Medicine
University of Nevada School of Medicine
Suite 300, 2040 W. Charleston
(702)671-2345
OVERVIEW
EDUCATIONAL PURPOSE
Rheumatology and non-operative (office) orthopedics deal with the prevention,
diagnosis, and management of crystalline diseases, systemic rheumatic diseases,
spondyloarthropathies, vasculitis, inflammatory muscle disease, osteoporosis,
osteoarthritis, recreational and sports injury, and soft-tissue diseases and trauma. The
goal of rheumatology is early diagnosis and treatment of these conditions to prevent
disability and death.
The general internist needs to have competency in the initial diagnosis and management
of acute arthritis and musculoskeletal disorders and in the long-term care of systemic
disorders. He or she must also be proficient in monitoring the effects of antiinflammatory, immunosuppressive and cytotoxic drugs.
Teaching Methods
The rotation will be under the supervision of the attending rheumatologist. The
resident(s) will accompany the rheumatologist to patient care locations in the outpatient
setting - patient care center (PCC – faculty practice) and Lied Clinic - and inpatient
consultations at UMC. The resident will see consultations and patients as assigned by the
attending rheumatologist. The resident will obtain the initial data, write a consultation
note, and present the patient to the attending physician. The attending will confirm the
findings, teach about the case, and with the resident, craft the final recommendations.
The resident will see the patient daily, write the follow up consult notes, and review them
with the attending rheumatologist.
Daily rounds will occur with the attending physician at which time instruction in the
unique aspects of the consultative process will be provided. Residents will be required to
continue their regular morning report and noon conference core curriculum. The resident
and attending will review and discuss any required reading.
1
Mix of Diseases
Patients present with a wide variety of rheumatologic problems including lupus
erythematosus, vasculitides, rheumatoid arthritis, crystalline arthritides, osteoarthritis,
psoriatic arthritis, traumatic synovitis, ankylosing spondylitis, and Reiter’s syndrome.
Patient Characteristics
The patient population is diverse, male and female, of all ages from adolescent to
geriatric, representing most ethnic and racial backgrounds, from all social and economic
strata. The hospital serves primarily the indigent population of the city of Las Vegas.
Types of Clinical Encounters
Patient encounters occur both in the inpatient setting on a consultative basis from other
clinical services and in the office as initial consultations or ongoing care of patients with
rheumatologic diseases.
Close interaction with various other healthcare team members including care managers,
discharge planners, home health agencies, inpatient nurses, respiratory therapists,
physical therapists, and patient care technicians occurs daily.
Common Clinical Presentations






Joint pain and/or swelling (acute or chronic, monoarticular or polyarticular)
Muscle aches (localized or diffuse)
Musculoskeletal weakness
Nonarticular signs and symptoms of rheumatologic disease, such as Raynaud’s
phenomenon and skin rash
Regional pain of the neck, shoulder, lower back, hip, knee, hands or wrists
Traumatic joint
Procedures
 Therapeutic injection of corticosteroid and arthrocentesis for the knee joint
 Therapeutic injection of corticosteroid to the periarticular structures (bursa) of the
shoulder, knee, elbow and foot
 Arthrocentesis of other joints (optional)
Primary Interpretation of Tests
 Analysis of synovial fluid
 Plain bone radiographs of joints and spine
Ordering and Understanding Tests
 Anti-ds DNA, anti-Sm, anti-RNP and anti-SS-A antibodies
 Antineutrophil cytoplasmic antibody (ANCA)
 Complement levels
 Erythrocyte sedimentation rate
 Fluorescent antinuclear antibody (ANA)
 Rheumatoid factor
 Synovial analysis for crystals
 Osteoporosis – GIM
2



Polymyalgia Rheumatica
Temporal Arteritis – GIM
NSAID Toxicity
Resident Supervision
Residents have constant on site supervision as well as daily personal supervision in their
patient care. The rotation will be under the supervision of the attending rheumatologist. The
resident(s) will accompany the Rheumatologist to patient care locations in the outpatient setting;
patient care center (PCC), Lied Clinic and inpatient consultations at UMC as assigned. The
resident will see consultations and patients as assigned by the attending rheumatologist write
initial and follow up consult notes and review them with the attending rheumatologist.
Didactic Teaching
Morning Report
Residents rotating on the rheumatology service are required to maintain greater
than 60 % attendance at morning report. Morning Report begins at 8 a.m. on
Monday through Thursday and at 8:30 a.m. on Friday.
Noon Conference
Residents rotating on the rheumatology service are required to maintain greater
than 60 % attendance at noon conference. Noon conference occurs daily, Monday
through Friday. These sessions cover the basic core curriculum, and other
curriculum topics such as ethical issues, geriatrics, computer systems and
informatics, health care systems, occupational and environmental health issues,
and other topics of concern. A rheumatologic topic is presented at least once
during each month.
Attending Rounds
Didactic discussions will be held regarding all patients seen in consultation during
the month. Each resident and medical student will be required prepare and
discuss during teaching rounds one article or rheumatologic topic each week.
Teaching rounds by the attending physician will occur every day for 45 - 60
minutes after regular management rounds. Each resident is required to review
common rheumatologic topics.
Core Reading Materials
Harrison’s Principle’s of Internal Medicine, 16th ed., Kasper DL, ed. McGraw
Hill
The Washington Manual of Medical Therapeutics, 32nd ed.
Kelley's Textbook of Rheumatology, Firestein GS, ed.
The Washington Manual Rheumatology Subspecialty Consult, Latinis K, ed.
Lippincott Williams & Wilkins
Ancillary Educational Materials
Subspecialty Texts of Neurology, Pulmonary Medicine, Nephrology,
Endocrinology, Infectious Diseases, Rheumatology as well as General Medical
3
References (Harrison’s Principles of Internal Medicine, Cecil’s Textbook of
Medicine) are available 24 hours a day, seven days a week in the resident lounge.
Savitt Medical Library On-Line
Residents have access to the on-line services of Savitt Library (the main library of
the University of Nevada - Reno) via their computer in the resident room, Suite
300 of the 2040 W. Charleston Building. Access to this room is available 24
hours a day, seven days a week.
Full text is available for many peer-review journals including, but no limited to:
ACP Journal Club
Annals of Internal Medicine
British Medical Journal
Cancer
Circulation
Journal of the American College of Cardiology
The Lancet
New England Journal of Medicine
Stroke
Also available on-line:
Harrison’s Principle’s of Internal Medicine, 14th ed.
Merck Manual, 17th ed.
Guide to Clinical Preventive Services, 2nd ed.
The Cochrane Library
Medline and Grateful Med Databases
Pathological Material and Other Educational Resources
Residents are encouraged to review the pathological reports on patients for whom they
have consulted and to follow the hospital care of those patients. If a patient with whom
the resident has consulted should die and have an autopsy, the resident is encouraged to
attend the post-mortem session.
Training Sites
University Medical Center
All of the inpatient rheumatology consultation experience occurs at University
Medical Center (UMC) under the supervision of one of the full-time
rheumatology faculty. The resident will also participate in the UMC outpatient
rheumatology clinic twice each month.
UNSOM Faculty clinics (Patient Care Clinic) and Lied Special Care Clinic
The resident will participate in rheumatology outpatient clinic under the
supervision of the full-time rheumatology faculty.
4
Competency-based Goals and Objectives
Rheumatology Rotation
Learning Venues
Evaluation Methods
1.
2.
3.
4.
5.
6.
Patient Care Center (PCC)
Lied Rheumatology Clinic
Attending Rounds UMC
Didactic Conferences
Self Study
Morning Reports (Rheum)
A.
B.
C.
D.
E.
F.
Competency Patient Care
Level Specificity
Attending evaluation
Direct Observation
Nursing evaluations
Self/Resident Evaluations
Departmental Tests/Evals
Patient Evaluation
R-1 = 1
R-2 = 2
R-3 = 3
Learning
Venues
1 , 2, 3, 4
Evaluation
Methods
A, B, C, D, F
1, 2, 3
1, 2, 3, 4, 6
A, B, D
1, 2, 3
1, 2, 3, 4
A, B, C
1, 2, 3
1, 2, 3
A, B, D
2, 3
1, 2, 3
A, B, D
3
Competency : Medical Knowledge
Learning
Venues
Evaluation
Methods
Level
Demonstrate knowledge of assessment of
acute and chronic arthritic conditions.
1, 2, 3, 4, 5, 6
A, B, E
1, 2, 3
Demonstrate knowledge of assessment
and management of auto immune disease.
a. Systemic lupus erythematosus
b. Rheumatoid arthritis
c. Rheumatic fever
d. Systemic sclerosis
e. Sjgren’s syndrome
f. Vasculitis, Behcet’s
g. Sarcoidosis, Amyloidosis
h. Spondyloarthropathies
Knowledge of relapsing polychondritis
1, 2, 3, 4, 5, 6
A, B, E
1, 2, 3
4, 5
E
2, 3
Competency: Interpersonal and
Learning
Evaluation
Demonstrate competency in obtaining
rheumatologic history from patients.
Demonstrate competency in physical
exam skills used to detect rheumatologic
disorders.
Demonstrate competency in assessment of
painful disorders.
Provide detailed treatment plan and
initiate treatment recommendations.
Teach more junior residents physical
exam skills.
Level
Level
5
Communication Skills
Venues
Methods
Interact in an effective way with
physicians, residents, nurses and medical
support staff.
Demonstrate understanding of patient
preferences in diagnostic evaluation and
management of critical situations.
Maintain accurate medical records.
Serve as a patient advocate.
Ensure adequate transfer of information
when consulting on a patient to another
physician (primary).
Communicate efficiently and effectively
with other consulting physician,
regarding diagnosis, treatment and
follow-up of seriously ill inpatients.
Communicate with patients and their
families regarding end-of-life issues,
categorization, organ donation, and
requests for autopsies.
1, 2, 3
A, B, C
1, 2, 3
1, 2, 3
A, B, C, F
1, 2, 3
1, 2, 3
1, 2, 3
1, 2, 3
A, B, C
A, B, C, F
A, B, C
1, 2, 3
1, 2, 3
1, 2, 3
1, 2, 3
A, B, C
2, 3
1, 2
A, B, C, D, F
1, 2, 3
Competency: Professionalism
Learning
Venues
Evaluation
Methods
Level
Treat team members, primary caregivers, and patients with respect and
empathy.
Understand, practice and adhere to a code
of medical ethics.
Participate actively during rounds.
Attend and participate in all scheduled
conferences.
Competency: Practice-Based Learning
1, 2, 3
A, B, C, D, F
1, 2, 3
1, 2, 3
A, B, C, D
1, 2, 3
1, 2, 3
3, 5
A, B, D
E
1, 2, 3
1, 2, 3
Learning
Venues
1, 2, 3, 4, 5
Evaluation
Methods
A, B
Level
1, 2, 4, 5
A, D
2, 3
1, 2, 3, 4, 5
A, D
2, 3
Incorporate case studies with relevant
research outcomes and report those
findings during clinical rounds.
Review the outcomes of patient care in
order to reflect on the approach taken in
the delivery of care.
Utilize established practice guidelines for
individual diseases to devise care
strategies.
2, 3
6
Identify limitations of one’s medical
1, 2, 4, 5
knowledge in evaluation and
management of patients and use medical
literature (primary and reference) to
address these gaps in medical knowledge.
A, E
1, 2, 3
Competency: Systems-Based Practice
Evaluation
Methods
Level
A, D, F
1, 2, 3
Learning
Venues
Understand need for effective
1, 2, 3
communication between multiple
caregivers (i.e. emergency room, critical
care unit, nurses, physicians, transporters,
outpatient clinic, radiology, chest pain
center, echo technicians).
Understand clinical trial design and the
1, 2, 3, 4, 5
statistical methods for evaluating
scientific studies, in cooperation with
attendings and research nurses/personnel.
Demonstrate competency in providing
1, 2, 3, 6
safety information including medication
interactions, near misses, etc.
A, B, C, E
2, 3
A, C, D
2, 3
EVALUATION
A. Of Residents
At the completion of each rotation, all clinical faculty are required to complete the
standard ABIM resident evaluation form. All clinical faculty are encouraged to
provide face-to-face feedback with the residents. The night-float resident is
evaluated by one of the three service attendings. In addition, residents may
receive interim feedback utilizing the ABIM’s Praise and Early Warning cards.
B. Of Rotation and Preceptor
All residents are encouraged to evaluate the rotation, and the clinical faculty
member, at the completion of the rotation. This evaluation form is included at the
end of this document. These evaluations are then converted to type and shared
anonymously with the clinical faculty.
The program director also discusses the rotation with the residents to ensure
rotation quality and satisfaction.
7
Rheumatology Rotation Resident Check List
1. Evaluation reviewed at mid-month and end of rotation by the supervising faculty
member and resident.
2. Completed assigned readings
3. Attended all assigned activities (excluding scheduled time away, required clinics and
emergencies).
4. Completed required case report abstracts and/or posters if assigned by the supervising
faculty member.
5. Demonstrated understanding of the basic principals of rheumatology.
6. Receive verbal feedback from attending at end of rotation.
Intern/Resident Signature_________________________
Date___________________
Supervising Attending Signature___________________
Date___________________
All items must be completed for rotation credit and checklist returned to the
Department of Medicine by the rotation’s end.
8