Faculty Chair:
John Andazola,MD
Contacts:
Required Experiences:
Memorial Medical Center
Optional Experience:
Elective rotations
Weekly Schedule PGY 2 or 3 :
| Sunday | Monday | Tuesday | Wed | Thursday | Friday | Saturday |
| Clinic | Rheum-AM | Rheum-AM | Clinic | Rheum-AM | ||
| Clinic | Rheum-PM | Didactics | Clinic | Clinic |
Requirements:
AOA
Internal Medicine
The program must provide at least thirty-two weeks of clinical training in internal medicine disciplines, including at least eight weeks of general internal medicine experiences during the OGME-1 year. This requirement can be met by either inpatient internal medicine or inpatient family medicine service.
At a minimum internal medicine training must include:
- Twenty-four weeks of inpatient experience.
- Four weeks of training in critical care medicine.
- Didactic and clinical training.
Internal medicine training shall include exposure to the following disciplines, in either inpatient or outpatient settings:
- Allergy and immunology.
- Cardiology.
- Dermatology.
- Endocrinology.
- Gastroenterology.
- Hematology.
- Infectious diseases.
- Nephrology.
- Neurology.
- Oncology.
- Pulmonology.
- Rheumatology.
ACGME
There must be specific subspecialty curricula to address the breadth of patients seen in family medicine. (Core)
The program must ensure that every resident has exposure to a variety of medical and surgical subspecialties throughout the educational program. (Detail)
Description of Rotation or Educational Experience:
Family physicians encounter a significant number of rheumatologic problems in the course of practice. Millions of work days are lost per year due to osteoarthritis and rheumatoid arthritis. The morbidity of arthropathies results in numerous hospitalizations annually.
Each family medicine resident should be aware of the impact of this group of diseases on the patient and the family and be capable of performing a history and physical examination with special attention to the musculoskeletal system. The resident should be able to perform appropriate laboratory tests and basic diagnostic procedures and to initiate a management and therapeutic plan for patients who have these diseases.
Rheumatologic diseases represent a growing health crisis and now affect 46.4 million people according to the National Health Interview Survey. In addition, 17.4 million people are disabled because of arthritic diseases. Given the number of patients, primary care physicians cannot rely on referral to rheumatologists to identify, diagnose and manage this growing health need. The family medicine physician is an integral part of the health care team that needs to recognize the importance of early diagnosis, treatment and holistic care of the rheumatologic patient. As part of a comprehensive treatment plan, family medicine physicians need competency in assessing patient understanding of the disease and how to participate in the treatment plan through self- management skills.
Family medicine physicians need to continually update their clinical knowledge given the new advances in rheumatologic diagnosis and treatments. The rheumatologic patient requires full-spectrum care that emphasizes the use of appropriate disease modifying agents and identifying when physical, occupational and rehabilitative therapy are necessary. Because family medicine physicians focus on comprehensive treatment, they have the unique skills to meet the demands of rheumatologic patients.
Expectations:
Residents
Residents are expected to arrive to rheumatology and continuity clinics on time and to dress and act in a professional manner. They are expected to contact the Rehumatology preceptors’ office prior to their first day on the rotation in order to arrange the initial meeting time and location of the rotation. It is expected that while at the preceptors’ office the residents will be respectful of the office space and personnel. The resident is responsible for maintaining a procedure log as well as completing assigned readings.
Faculty:
Family medicine faculty will provide precepting of rheumatologic cases and procedures as seen in resident continuity clinics. Dr. Rene, and possibly other physicians in his practice, will provide precepting during the focused Rheumatology rotation. The faculty and preceptors are expected to allow the resident to participate in active patient care and procedures when appropriate. The preceptors should also provide time and allowance for explanation and teaching of rheumatologic conditions and their treatments.
Call:
There is no call specific to this rotation.
Patient Care
Goal
Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents are expected to:
Competencies
- Competently perform diagnostic, therapeutic and rehabilitative examination and treatment of the rheumatologic patient. (Medical Knowledge, Patient Care)
- Optimize treatment plans with consultation of the local rheumatologist and arthritis resources that include local, state and federal agencies. (Systems-based Practice, Practice-based Learning)
- Demonstrate comprehensive, culturally competent communication with each patient and his or her family in order to ensure clear understanding of the diagnosis, treatment and rehabilitation. (Interpersonal Skills, Communications, Patient Care)
- Recognize that the treatment of rheumatologic diseases requires a multidisciplinary approach and when necessary, may also require urgent referral and consultation to provide optimal patient care and decrease disability. (Medical Knowledge, Systems- based Practice, Practice-based Learning)
Objectives:
In the appropriate setting, the resident should demonstrate the ability to independently perform or appropriately refer:
- The basic elements of a rheumatic assessment (including a targeted history, musculoskeletal examination and functional assessment).
- Development of a differential diagnosis based on the pattern of joint and soft tissue involvement such as symmetrical small joints, non-symmetrical large joints and axial skeleton.
- The ordering of appropriate laboratory tests based on initial evaluation and interpretation of the results.
- Joint and bursal aspirations and interpretation of results for crystal, inflammatory or infectious causes.
- The ordering of appropriate radiographic views of involved joints and interpretation of results with emphasis on soft tissue changes and early erosive changes.
- Evaluation of limitations inactivities of daily living and affect on social and psychological status of the patient.
- Recognition of urgent joint conditions such as“theredhotjoint”andperforming appropriate synovial fluid aspiration and analysis.
- Treatment of rheumatologic conditions and the monitoring of the laboratory, physical exam and potential side effects in consultation with a rheumatologist.
- The use of many modalities for pain control (including oral pharmacologic agents, physical therapy, acupuncture and intra-articular and soft tissue aspirations and injections.
- The utilization of traditional treatment modalities (including physical therapy, splinting devices and assistive or offloading devices).
- Communication to the patient and family regarding the proposed investigation, treatment and community resources available to promote understanding and compliance for optimal patient care.
- A focused history, musculoskeletal exam and laboratory evaluation to evaluate disease progression.
- The inclusion of a multidisciplinary approach to the treatment of rheumatologic conditions and appropriate referral to orthopedic surgeons, rheumatologists,
physiatrists, psychologist or psychiatrists, nutritionists and physical and occupational therapists.
Medical Knowledge
Goal
Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, as well as the application of this knowledge to patient care. Residents are expected to:
Competencies
- Be able to understand normal neurological development, anatomy and physiology.
Objectives:
In the appropriate setting, the resident should demonstrate the ability to apply knowledge of:
- Anatomy and physiology of the normal musculoskeletal system and the immunologic processes that contribute to the pathogenesis of rheumatic disease
- The appropriate focused history for joint and soft tissue symptoms, screening,a complete musculoskeletal examination, functional assessment and use of laboratory and imaging modalities:
- Indications for and interpretation of arthrocentesis
- Indications for and interpretation of tissue biopsy results
- Indications for arthroscopy
- The clinical presentation, diagnostic criteria and initial treatment for various rheumatologic conditions with special emphasis on osteoarthritis, gout, rheumatoid arthritis, Lupus erythematosus and polymyalgia rheumatica:
- Arthralgia
- Osteoarthritis (OA) including primary and secondary
- Rheumatoid arthritis (RA) with manifestations of articular, extra-articular and
- juvenile forms
- Spondyloarthritis
- Ankylosing spondylitis
- Reiter’s disease
- Psoriatic arthritis
- Arthritis associated with inflammatory bowel disease
- Infections that cause direct and indirect forms of arthritis
- Acute rheumatic fever
- Subacute bacterial endocarditis
- Post-dysenteric
- Crystal-induced arthropathies
- Gout
- Acquired
- Calcium pyrophosphate dihydrate (pseudogout)
- Hydroxyapatite deposition
- Neoplasms that cause arthropathies
- Drug-induced
- Connective tissue disorders
- Lupus erythematosus (LE) with various presentations (including systemic, discoid and drug-induced)
- Scleroderma with various presentations (including localized, systemic and drug/toxin-induced)
- Polymyositis and dermatomyositis and their relationship to connective tissue disorders as distinguished from drug-induced myositis
- Sjögren’s syndrome (primary and secondary)
- Polymyalgia rheumatica
- Antiphospholipid syndrome
- Vasculitis
- Polyarteritis nodosa
- Microscopic polyangiitis
- Hypersensitivity angiitis
- Serum sickness
- Henoch-Schönlein purpura
- Granulomatous arteritis
- Wegener’s granulomatosis
- Giant Cell (temporal) arteritis
- Kawasaki disease
- Behcet’s disease
- Regional rheumatic pain syndromes
- Bursitis
- Tendinitis and tendinosis
- Low back pain
- Costochondritis
- Chondromalacia patellae
- Compression
- Peripheral entrapment (e.g., carpal tunnel)
- Radiculitis and radiculopathy
- Spinal stenosis
- Raynaud’s phenomenon
- Complex regional pain syndrome
- Other
- Osteopenia and osteoporosis
- Osteomalacia
- Paget’s disease
- Avascular necrosis
- Relapsing panniculitis (Weber-Christian disease)
- Erythema nodosum
- Sarcoidosis
- Adult Still’s disease
- Fibromyalgia and chronic fatigue syndrome
- Arthralgia
- The indications, laboratory and exam monitoring, potential side effects and contraindications of pharmacologic agents for analgesia, disease modification, immunosuppression and anti-inflammation
- Define the mechanism of action of different analgesic medications (including acetaminophen, COX 2 inhibitors, tramadol and narcotics)
- List the mechanisms of the different disease modifying agents (including antimalarials, sulfasalazine, minocycline and gold salts)
- List the mechanism of action of different immunosuppressive agents including penicillamine, cytotoxic agents such as methotrexate, and biologic agents such as anti-tumor necrosis factor and IL-1 receptor antagonists)
- List the indications for use of local and systemic preparations of corticosteroids in different rheumatic conditions
- Describe the use of uricosuric agents for prevention of gouty attacks and the use of abortive agents in acute attacks
- Describe the role of antibiotics in the treatment of rheumatic conditions
- List the various medications and special circumstance for each agent in the treatment of osteoporosis
- The use of rehabilitation services for joint mobilization, physical conditioning,and modalities for different stages of rheumatologic conditions to promote function and prevent physical disability
- A multidisciplinary approach to the treatment of rheumatologic conditions that utilizes expertise resources (including a rheumatologist, physiatrist, physical and occupational therapist, orthopedic surgeon and mental health provider) for optimal patient care
- Complementary therapies and modalities available to rheumatic conditions (including supplements, chiropractic and acupuncture)
- Disability prevention in rheumatologic conditions which includes appropriate general health maintenance with attention to necessary vaccinations, appropriate weight maintenance with nutrition and exercise counseling, and attention to controlling other co-morbid medical conditions.
Practice Based Learning and Improvement
Goal
Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life long learning. Residents are expected to develop skills and habits to be able to:
Competencies
- Be able to recognize his or her own practice limitations and seek consultation with other health care providers to provide optimal care.
Objectives
- Complete assigned reading topics and apply learned material in the clinical setting
- Demonstrate ability to identify limitations in own knowledge and take steps to fill these gaps.
System Based Practice
Goal
Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. Residents are expected to:
Competencies
- Be able to optimize treatment plans based on knowledge of local resources that include local, state and federal agencies.
- Coordinate ambulatory, in-patient and institutional care across health care providers, institutions and governmental agencies.
Objectives
- Make appropriate referrals to and coordinate care with neurologists for those conditions that fall out of the scope of family medicine or do not respond to that treatment which family physicians can provide
- Demonstrate cost effective care and diagnostic testing
Professionalism
Goal
Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. Residents are expected to demonstrate:
Competencies
The list below reflects competencies that fall under Professionalism. Which of the following competencies are relevant for the rotation or educational experience you have chosen? (Pick one or two)
- Compassion, integrity, and respect for others
- Responsiveness to patient needs that supersedes self-interest
- Respect for patient privacy and autonomy
Objectives
- Display sensitivity for patient privacy and autonomy during exams and procedures
- Engage in interviewing techniques which demonstrate cultural and social sensitivity
Interpersonal and Communication Skills
Goal
Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and teaming with patients, their families, and professional associates. Residents are expected to:
Competencies
The list below reflects competencies that fall under Interpersonal and Communication Skills. Which of the following competencies are relevant for the rotation or educational experience you have chosen? (Pick one or two)
- Communicate effectively with patients and families across a broad range of socioeconomic and cultural backgrounds
- Act in a consultative role to other physicians and health professionals
Objectives
Communicate with patients and their families in a respectful, and concise manner that facilitates understanding with minimal jargon.
Teaching Methods
Residents will provide medical care to patients under the direct supervision of the attending physician. They will be supervised on all procedures performed. They will participate in weekly conferences. Residents will be assigned specific reading topics to be completed by the end of their month on the service.
Assessment Method (residents)
Direct observation with a ongoing global assessment based on the REDI system. All procedures will be recorded on New Innovations and independence for each procedure assessed using the REDI system. Evaluation from each of the community preceptors to be completed at the end of the rotation. Review of documentation by family medicine preceptors as part of continuity clinic supervision.
Assessment Method (Program Evaluation)
Residents will be provided with an evaluation of their experiences and given the opportunity to provide feedback of the rotation during their quarterly IEP assessments.
Level of Supervision
The resident is directly supervised by the attending physician during all procedures performed. An Attending will be available the entire time the resident is on the rotation. An Attending will be available at all times during continuity clinic visits.
Educational Resources
Readings:
Week 1
Week 2
Week 3
Week 4
Text Books
Resources
Rodinelli RD, Genovese E, Brigham CR. Guides to the Evaluation of Permanent Impairment. 6th ed. Chicago, Ill.: American Medical Association, 2008.
Guidelines for the Management of Rheumatoid Arthritis. Arthritis and Rheumatism. 2002, 46(2):328-46.
Koopman WJ, Boulware DW, Heudebert GR. Clinical Primer of Rheumatology. Philadelphia, Pa.: Lippincott Williams & Wilkins, 2003.
Harris ED, Kelley WN. Kelley’s Textbook of Rheumatology. 7th ed. Vols 1 and 2. Philadelphia, Pa.: Saunders Elsevier, 2005.
Klippel JH. Primer on the rheumatic diseases. 13th ed. Atlanta, Ga.: Arthritis Foundation, 2008.
Stuart MR, Lieberman JA. The Fifteen Minute Hour: Practical Therapeutic Interventions in Primary Care. 3rd ed. Philadelphia, Pa.: Saunders, 2002.
Koopman WJ, Moreland LW. Arthritis and Allied Conditions: A Textbook of Rheumatology. 15th ed. Philadelphia, Pa.: Lippincott Williams & Wilkins, 2005.
Hochberg MC. Rheumatology. Vols 1 and 2. 4th ed. Philadelphia, Pa.: Mosby/Elsevier, 2008.
Web Sites
National Arthritis Foundation
SNMFMRP Curriculum 