Methodology for Teaching Rheumatology

The Consultation Experience

Fellows develop strong leadership skills during their one-week rotations on the consultation service.

• Fellows direct the consult team, which consists of a supervising faculty physician and typically one or more Internal Medicine resident physicians.  The additional presence of resident physicians, medical students and occasional physician assistant students provides ample opportunities for teaching and management of complex teams.
• Faculty physicians provide extensive feedback to fellows so that fellows can develop and refine their clinical skills in evaluating and treating patients, including
  • Acquisition and analysis of clinical data,
  • Synthesis of an appropriate list of differential diagnoses
  • Formulation of an individualized treatment plan
• Most consult requests occur in the inpatient or emergency room setting.  There is considerable variability in the number and types of consults, although typically the number of inpatient consults hovers between 2 and 8 patients at a time.
• Each fellow spends about 15-18 weeks on call per year, depending on the presence of any dual-certified Allergy/Immunology and Rheumatology fellows. The number of weeks on call is lower in the second year to accommodate increased scholarly activity.
• While on call, fellows continue having their outpatient clinics and have one extra access clinic, typically on Monday mornings.
• To support fellow well-being, faculty physicians are strongly encouraged to avoid rounding after hours (beyond 5pm on weekdays).
• Consultation experiences provide ample opportunities to practice and develop procedural skills including arthrocentesis, diagnostic ultrasonography, and crystal analysis.
• Face-to-face sessions prior to the rotation to better understand and prioritize the fellow’s educational goals are strongly encouraged, as well as follow-up sessions immediately thereafter to provide formative evaluation of the consultation experience. 

Fellows also cover inpatient consultations at the Iowa City Veterans Affairs Health Care System.  For each month, there is a designated on-call VA fellow who works with the on-call faculty physician.  VA consultations range from 0 to 4 requests per month.

The Continuity of Care Experience

Each fellow is assigned two Continuity of Care (CoC) clinics, one at the University of Iowa and the other at the Veterans Affairs Health Care System.

• Fellows provide longitudinal care to their panel of patients throughout the 24 months of their fellowship. 
  • This enables fellows to assume direct responsibility for the evaluation and treatment of patients that they see. 
  • It also fosters long-term relationships and partnerships with patients to improve the quality of care.
• CoC clinics provide opportunities to learn about outpatient evaluation and treatment of rheumatologic disorders. Fellow physicians work with the on-call faculty physician to craft plans of care.
• CoC clinics are interdisciplinary.  They have dedicated specialty pharmacist, schedulers, nurses, and medical assistants in the clinic space to facilitate the evaluation and treatment of patients. This interprofessional clinical team maximizes the educational experience of fellows.
• Both the UIHC Rheumatology Clinic and VA Rheumatology Clinics have dedicated ultrasound machines that are available for fellows for clinical use and educational purposes.
• Fellows are encouraged to design and implement quality improvement initiatives to facilitate care of patients.

First-year fellows also attend the General Rheumatology Clinic at the VA once per week.

Interdisciplinary Interactions

The Division of Immunology actively fosters interactions and collaborations with clinicians in other specialties. This culture of cooperation has enabled us to create dedicated rotations in pediatric rheumatology and musculoskeletal radiology.

Pediatric rheumatology:

First-year fellows attend pediatric rheumatology clinics approximately every other week. These clinics provide excellent opportunities to learn about autoinflammatory disorders, juvenile idiopathic arthritis, and other pediatric autoimmune diseases. Additionally, there is a monthly Pediatric/Adult Rheumatology Case Conference to discuss challenging and interesting cases of rheumatologic disorders from infancy to old age.

Musculoskeletal radiology:

First-year fellows also have reserved time (typically 2 to 4 weeks) to learn about musculoskeletal radiology with dedicated MSK radiologists. Fellows develop fluency in reading X-rays of joints commonly involved in rheumatologic diseases, as well as familiarity with the interpretation of MRIs and CT scans. In addition, fellows coordinate with MSK radiology fellows to run the monthly Rheumatology-Radiology Conference, in which images from challenging or illustrative cases are discussed at length. 

Electives:

A major strength of our fellowship curriculum is its flexibility.  Electives from other disciplines are available to interested fellows.  These include outpatient experiences in allergy/immunology, orthopedic medicine, rehabilitative medicine (physical and occupational therapy), dermatology, ophthalmology, endocrinology, and pulmonology, among others.

Group and Individual Learning Activities

Wednesday afternoons are reserved for didactic activities, including Grand Rounds and Small Group Fellow Conferences.  

Immunology Grand Rounds:

• We hold weekly Immunology Grand Rounds, in which faculty and fellows from Rheumatology and Allergy/Immunology participate to discuss basic science and clinical topics common to both subspecialties.
• Fellows present for Immunology Grand Rounds at least once per year on a topic of their choice, as well as prepare a Research-in-Progress talk toward the end of their first and second years.
• During the summer, there is a dedicated ‘Immunology Boot Camp,’ consisting of six sessions reviewing essential concepts in basic and clinical immunology.  

Small Group Sessions:

• Small group sessions geared specifically toward rheumatology fellows are also held once per week, immediately after Immunology Grand Rounds.
• The formats of these conferences vary considerably depending on the objectives. These include formal case presentations, journal club, research presentations, and didactic conferences.
• The division strongly emphasizes taking advantage of these Small Group Sessions to promote interactive discussions geared specifically toward fellow physicians.
• During weeks in which there are interdisciplinary conferences (like Pediatric/Adult Rheumatology Case Conference or Rheumatology-Radiology Conference), Small Group Sessions are cancelled.

Board Review Sessions:

• Additionally, rheumatology fellows attend Board Review sessions every Thursday afternoon.
• Board Review sessions are highly interactive and cover a variety of topics and strategies in order to pass the American Board of Internal Medicine Rheumatology Board Certification Examination.
• The structure of these sessions vary from year-to-year in order to accommodate the different learning styles of different fellows.

Summer Hands-On Workshop Sessions:

• Additionally, fellows have a series of hands-on workshop sessions that are held during the summer.  This innovative series, which lasts for 10 weeks, integrates teaching for musculoskeletal ultrasound, regional physical examination skills, and arthrocentesis.
• Successful completion of this seminar series fulfills one component of the pathway towards RhMSUS (Rheumatology Musculoskeletal Ultrasound) certification. Fellows are also encouraged to apply for the USSONAR (Ultrasound School of North American Rheumatologists) course for advanced training.
• To learn more about ultrasound learning, click here.

Other Didactic Sessions:

Rheumatology fellows also regularly share conferences with other Internal Medicine fellows.  These include:

• The Interdisciplinary Fellowship Conference, which occurs approximately once per month.
• Internal Medicine Grand Rounds, which occurs weekly on Thursday afternoons
• Immunology Group Seminar, which occurs on Wednesday afternoons
• Fellows as Clinical Educators (FACE) Program.

Individual Virtual Learning Opportunities

Our fellowship program also provides a robust array of asynchronous virtual learning opportunities for fellows.  This allows rheumatology fellows to engage with the material on their own terms and pace.

To prompt completion of these asynchronous exercises, fellows are typically assigned one of each of the following per week.

The Hawkeyes Rheumatology Question Bank:

• Rheumatology Fellows have access to an item bank of 1900 multiple-choice questions that covers content tested on the Rheumatology certification examination. 
• These items have been drafted in accord with Best Practices for Test-Item Writing and have been psychometrically validated.

The Hawkeyes Core Casebook:

• Rheumatology fellows also have access to the Core Casebook.  The Core Casebook consists of 360 Script Concordance Test items across 48 vignettes of 12 patients.
• These script concordance test items have been designed to probe and assess diagnostic reasoning and are based on real-life patient cases.
• An example of a vignette can be found here.

The Clinical Reasoning in Immune System Pathogenesis (CRISP)

• Because application of clinical immunology is often difficult to master for rheumatology fellows, we have an innovative set of exercises that link knowledge of basic science immunology to skills necessary for clinical practice. 
• Fellows have access to 150 CRISP questions from 15 vignettes.
• An example of a CRISP question set can be found here.

Continuing Medical Education and Society Memberships

In addition to participating in the organized didactic conferences established within the fellowship program, all fellows are strongly encouraged to become members of and volunteer with the American College of Rheumatology (ACR).

The division pays for Fellows-in-Training membership in the ACR and encourages annual attendance to at least one ACR national meeting (Convergence, ACR Education Exchange)
Funds are available for travel to conferences where fellows are presenting original research

Fellows also play a pivotal role in organizing the Iowa Rheumatology Symposium, an annual meeting of rheumatologists in the state of Iowa. This includes preparing case presentations and didactic lectures, in conjunction with faculty, regarding a selected theme for the year.

The Division of Immunology also encourages fellows who apply to the Ultrasound School for North American Rheumatologists (USSONAR) to obtain advanced training in musculoskeletal ultrasound.

Scholarly Activity/Research Experience

All fellows participate in scholarly activities throughout the course of their fellowship. Fellows are strongly encouraged to identify topics that interest them, and to develop their research plans with mentors either within the division or outside of it. All fellows are exposed to divisional research early in their fellowship to allow adequate insight into areas of active research at the institution.

Once a project is selected, the division helps to facilitate regular meetings with the research mentor. Research conferences during Small Group Sessions and Research-in-Progress talks provide opportunities for other faculty members and fellows to give feedback and to disseminate preliminary results in a friendly and collegial atmosphere.

Previous fellows have performed basic science, patient-centered, translational, medical education, and outcomes-based research, and have published their findings in peer-reviewed journals as well as presented them at national meetings. Fellows have written case reports, case series, commentaries, observational studies, clinical trials, narrative reviews, and systematic reviews.