Rheumatology

I. GOALS AND OBJECTIVES:

A. Goals:

The rheumatology elective is designed to equip residents with the clinical skills needed to recognize and manage common rheumatic diseases. It is well known that early diagnosis and treatment of rheumatic conditions improves patient outcomes and reduces the medical and social impact of these diseases (1). By exposing residents to rheumatology in both the inpatient and outpatient settings, a complete understanding of these disease processes is fostered. Residents are encouraged to appreciate the individual and multispecialty approaches to caring for rheumatology patients. The elective also combines direct patient care with basic science seminars and an understanding of the pathogenesis of arthritis, metabolic bone disease and autoimmunity. At the end of the rotation the resident can expect to be comfortable with the diagnosis, investigation and management of common rheumatic diseases and the recognition of less common syndromes thus facilitating their prompt referral for specialized care.

The rheumatology elective is a one block rotation (of approximately 2 or 4 weeks duration) and involves participation in the in-patient rheumatology consultation service, two weekly out-patient arthritis clinic sessions, one weekly out-patient systemic lupus erythematosus (SLE) clinic session, two weekly journal clubs and one rheumatology seminar/grand round conference.

The rheumatology elective is available to all Internal Medicine residents.

PGY Level 1, 2, 3 Competency Based Objectives:

The residents will function as members of the Consult Team, as such their level of independence and responsibility given will be PGY year dependent. However, all members of the team are expected to demonstrate competency in the following areas:

- Patient Care: Prioritize the day’s work schedule; recognize the relative significance of a given patients rheumatologic conditions; begin to recognize acuity of illness; understand the indications, contraindications, and risk of common procedures used in the specialty; work with all providers to extend quality care at all times; supervise the junior staff in patient care, including rotating medical students.

- Medical Knowledge: Use literature and reference sources to increase knowledge base; demonstrate basic knowledge in the areas of underlying pathophysiology of connective tissue, and the clinical aspects of common and/or organ/life threatening rheumatologic diseases; apply knowledge in the treatment of patients

- Professionalism: Establish trust with patients, other caregivers and staff; exhibit honesty, reliability and responsibility in patient care; demonstrate respect for patients and all staff including ancillary personnel; work to fulfill the needs of patients; accept assignments graciously; attend divisional conferences; respond promptly to consultation requests

- Interpersonal Skills: Write understandable and timely notes; develop the ability to listen to patients, families, staff and ancillary personnel; communicate verbally and nonverbally in a productive and constructive manner; work effectively as a member of the health care team

- Practice Based Learning and Improvement: Recognize accept the limitations of ones knowledge and use that as an opportunity for personal growth; use references and literature (including computer based resources) in professional communication and to improve practice patterns; accept feedback willingly and change behavior appropriately; ask for help when needed

- Systems Based Practice: Be the patients’ advocate; learn about health care system and structure (locally/regionally); begin to develop mechanisms to utilize ancillary services to benefit patients

II. AREAS COVERED DURING ROTATION:

1. Pathophysiology and Basic Sciences of the Rheumatic Diseases and Immunology:

Residents develop an understanding of the pathogenesis of rheumatic disease through direct one on one interaction with teaching staff and through exposure at divisional conferences, becoming familiar with:

a) The pathogenesis of rheumatoid arthritis

b) The pathgenesis of autoimmunity

c) Understanding Connective Tissue Diseases

d) Understanding Metabolic Bone Disease

e) Understanding osteoarthritis

2. Practice skills unique to Rheumatology:

a) The history and physical examination in the rheumatology patient: differentiating localized pathology from systemic disease and understanding the signs and symptoms of inflammation as distinct from the biology of metabolic and degenerative diseases.

b) Explain the usefulness of investigations for rheumatic disease including antibody profiles in autoimmune diseases; the use of the sedimentation rate, C-Reactive protein and other acute phase reactants in diagnosing inflammatory rheumatic diseases.

c) Identify the utility of specific tests for rheumatic disease and their appropriate use as diagnostic and prognostic markers; e.g. the anti-CCP antibody in rheumatoid arthritis.

d) Describe the use of Disease Assessment Tools in monitoring patient’s disease activity indices, response to treatment, and also for when treatments fail and need to be adjusted.

e) Appreciate the importance of patient compliance in treating rheumatic diseases including gout, rheumatoid arthritis, systemic lupus erythematosus and osteoporosis.

f) Develop an understanding of the medical, economic and social costs of rheumatic diseases both to the individual and to society at large and appreciating the importance of early and optimal intervention.

g) Explain the significance of arthrocentesis, soft tissue and joint injections.

3. Approach to common presenting complaints/problems in Rheumatology:

a) Acute arthritis

i) Acute monoarthritis

ii) Acute oligoarthritis

iii) Acute polyarthritis

b) Chronic Arthritis

i) Chronic monoarthritis

ii) Chronic oligoarthritis

iii) Chronic polyarthritis

c) Rash with arthritis

d) Myopathy with arthritis

e) CNS disease and Neuropathy with arthritis

f) Postinfectious arthritis syndromes including HIV

g) Gastroenteric complaints and rheumatology

h) Renal disease in rheumatology

i) Nephritis

ii) Nephrosis

i) The eye in rheumatic disease

j) Rheumatic complaints without frank arthritis

k) Pregnancy and rheumatic disease

l) The pediatric rheumatology patient

4. Specific Diagnoses in Rheumatology

a) Inflammatory polyarthritis, eg: Rheumatoid and Psoriatic Arthritis

b) Systemic Lupus Erythematosus

c) Scleroderma/Systemic sclerosis

d) Polymyositis

e) Spondyloarthropathies

f) Vasculitis

g) Crystal-Induced Synovitis

h) Osteoarthritis

i) Regional musculoskeletal pain syndromes, and acute and chronic muskuloskeletal pain syndromes

j) Nonarticular rheumatic diseases, including fibromyalgia

k) Postinfectious arthritis

l) Nonsurgical, exercise-related (sports) injury

m) Soft tissue arthritis

n) Systemic diseases with rheumatic manifestations

o) Rheumatic manifestations of malignant diseases

p) Osteoporosis

q) Infections of joints, bones and soft tissues

r) Sjogren’s syndrome, overlap syndromes and mixed connective tissue disease

s) The rheumatic manifestations of autoimmune thyroiditis and autoimmune liver disease

t) Pediatric rheumatic conditions

u) The psychological impact of rheumatic diseases and chronic pain syndromes

5. Emergencies/Therapeutic Interventions:

a) Severe lupus nephritis

b) Severe thrombocytopenia and thrombotic thrombocytopenic purpura in the lupus patient

c) Lupus cerebritis and transverse myelitis

d) Life threatening lupus pneumonitis

e) Giant cell arteritis with visual loss and CNS involvement

f) Conservation of renal function in scleroderma renal crisis

i) Prompt ACEI use, BP control

g) Life-threatening vasculitis

h) Septic Arthritis

6) Technical Skills:

a) Joint and muskuloskeletal examination

b) Joint aspiration and injections

c) Soft tissue injections

d) Microscopic examination of aspirated or expressed crystal material and other pathological specimens

i) Light microscopy

ii) Polarized light microscopy

iii) Fluorescence microscopy

e) Interpretation of Radiographs and Bone densitometry data

f) Urinalysis

g) Fundoscopic examination and nailfold capillaroscopy

h) Interpretation of laboratory data including autoantibody profiles and genomic and proteomic analysis; e.g. IF, ELISA and Western blot interpretation

i) Understanding the genetic evaluation of heritable rheumatic conditions; e.g. FMF, other periodic feveres and amyloidosis

III. SCHEDULE OF ACTIVITIES

IV. REFERENCES

Residents on elective will obtain access to the Division of Rheumatology online article collection.