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Methology for Teaching Rheumatology

In order to achieve the goals and objectives for the fellowship program, the following activities have been established for the purpose of teaching rheumatology fellows. 

1.  The Consultation Experience

Fellows participate in one-week rotations on the consultation service, which includes both outpatient and inpatient activities. Fellows lead the clinical team under direct supervision of the attending physician to evaluate and treat patients with rheumatologic diseases at University of Iowa Hospitals & Clinics and the Veterans Affairs Medical Center. These include inpatient and emergency treatment center consultations as well as management and triage of urgent outpatient consultation requests.

Fellows are expected to lead the team, which is composed of the fellow physician, the attending physician, and, depending on the schedule, an Internal Medicine resident physician, and/or medical students. Fellows are expected to 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, and formulation of an individualized treatment plan. Fellow physicians are strongly encouraged to develop leadership and management skills in delegating tasks among team members and fostering communication. Fellows are also integral to the educational mission of the consultation experience; they are expected to perform literature searches pertinent to the cases at hand and to teach other team members and consulting providers. Finally, consultation experiences provide ample opportunities to practice and develop procedural skills including arthrocentesis, diagnostic ultrasonography, and crystal analysis.  

In turn, attending physicians are expected to provide timely feedback on performance, including for clinical skills, procedural skills, and documentation. 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. 

2. The Continuity of Care Experience

Each fellow is assigned a weekly Continuity of Care (CoC) Clinic at the University of Iowa and at the Veterans Affairs Medical Center throughout the 24 months of fellowship. Fellows are expected to assume direct responsibility for evaluation and treatment of patients that they see, under the supervision of the attending physician. Additionally, first-year fellows attend the General Rheumatology Clinic at the VA once per week.

CoC clinics provide opportunities to learn about outpatient evaluation and treatment of rheumatologic disorders. Fellow physicians work with the attending physician, as well as a dedicated specialty pharmacist, schedulers, nurses, and medical assistants to evaluate and treat patients at consultation and follow-up appointments.  This interprofessional clinical team maximizes the educational experience of fellows.

The CoC experiences at the University of Iowa and the VA allow for opportunities to learn and practice musculoskeletal ultrasonography. There are dedicated point-of-care ultrasound machines available for fellow physicians at both sites.

3. Interdisciplinary Interactions

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

First-year fellows attend pediatric rheumatology clinics approximately every other week. These clinics provide excellent opportunities to learn about juvenile arthritides, autoinflammatory disorders, 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.

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. 

Our curriculum is flexible enough to incorporate elective rotations with other disciplines, including clinical immunology/allergy, orthopedic medicine, rehabilitative medicine (physical and occupational therapy), dermatology, ophthalmology, endocrinology, and pulmonology, among others. The division leadership may facilitate creation of these rotations, or others, at the request of interested fellows.

4. Small Group Conferences

Wednesday afternoons are reserved for didactic activities, including Grand Rounds and Small Group Fellow Conferences. Attendance is required for both faculty and fellow physicians.  

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 are expected to 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 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.

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. These sessions alternate between completing board-style questions and reviewing disease-specific topics.

Furthermore, there is a dedicated 10-week intensive Musculoskeletal Ultrasound Seminar Series occurring every six months. 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.

Rheumatology fellows also regularly share conferences with other Internal Medicine fellows. This includes the Interdisciplinary Fellowship Conference, which occurs approximately once per month.

Other didactic conferences are available to fellows if they are interested. These include Internal Medicine Grand Rounds, Immunology Group Seminar, and the Fellows as Clinical Educators (FACE) Program.

5. 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 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 of (the Annual Conference, State-of-the-Art meeting, or the Rheumatology Research Workshop). To those presenting original research, funds are available for travel.

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.

6. Scholarly Activity/Research Experience

All fellows are expected to participate in scholarly activity. 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.