EDUCATIONAL GOALS, OBJECTIVES, METHODS, AND EVALUATIONS Rheumatology Fellowship Training Program University of Colorado Health Sciences Center

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1 EDUCATIONAL GOALS, OBJECTIVES, METHODS, AND EVALUATIONS Rheumatology Fellowship Training Program University of Colorado Health Sciences Center I. Goals and Core Competencies of the Rheumatology Fellowship Training Program A. To train physicians to provide patient care that is compassionate, appropriate, and effective for the treatment of rheumatic disease, other associated health problems, as well as the promotion of health. B. To provide physicians with a solid foundation in the basic and clinical science of rheumatology so they can demonstrate medical knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and socialbehavioral) sciences and apply this knowledge to patient care and performance of research in the rheumatic diseases. C. To instill in physicians a commitment to professionalism so that they carry out their professional responsibilities, adhere to ethical principles, and are sensitive to diverse population as they care for patients and/or perform research in rheumatology. D. To instill in physicians a life-long commitment to practice-based learning and improvement so that they investigate, evaluate, and improve their patient care practices, appraise and assimilate scientific evidence, possess the skills to competently educate medical students/physicians/other health care professionals about rheumatic diseases, and improve their research practices in rheumatology. E. To produce physicians who possess the interpersonal and communication skills that result in effective information exchange and teaming with patients, their patient's families, and professional associates in the care of rheumatology patients. F. To train physicians to be aware of and responsive to the larger health care system and effectively call on system resources to provide care that is of optimal value for patients with rheumatic diseases ( i.e. system-based practice). G. To train physicians to have the ability to work in a variety of settings as primary health care advisor, consultant to other physicians, as the leader of a multidisciplinary health care team caring for patients with rheumatic diseases, and/or as a researcher.

2 II. Objectives of the Rheumatology Fellowship Training Program At the completion of the rheumatology fellowship training program, the trainees are expected to demonstrate they have mastered the following objectives as they pertain to the educational goals of the rheumatology fellowship listed above (see core curriculum). A. PATIENT CARE - communicate effectively and demonstrate caring and respectful behaviors when interacting with patients and their families which facilitates establishing rapport with them gather essential and accurate information about their patients through history, physical examination, and review of records make informed decisions about diagnostic and therapeutic interventions based on patient information, differential diagnosis, preferences, up-to-date scientific evidence, and clinical judgment orders appropriate tests and properly interprets test results develop and carry out patient management plans counsel and educate patients and their families use information technology to support patient care decisions and patient education plan and perform competently all medical and invasive procedures considered essential for the area of rheumatology after obtaining necessary consent to proceed provide health care services aimed at preventing health problems or maintaining health work with health care professionals, including those from other disciplines, to provide patient-focused care B. MEDICAL KNOWLEDGE (see core curriculum) demonstrate an investigatory and analytic thinking approach to clinical rheumatology situations know and apply the basic and clinically supportive sciences which are appropriate for the care of rheumatic disease patients

3 consider evidence-based information for the care of patients with rheumatic diseases consider the range of therapeutic interventions in the rheumatic diseases demonstrate knowledge of practice guidelines for care of rheumatology patients demonstrate knowledge of the process and skills required for basic science, health services, and/or clinical research in the rheumatic diseases C. PROFESSIONALISM demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supersedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development Examples include: - punctuality and respect for others' time - complete record and documentation requirements timely and appropriately - attempt to learn from mistakes demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices demonstrate sensitivity and responsiveness to patients' culture, age, gender, and disabilities demonstrate preparation and organization effectively and professionally teaches and mentors junior residents and students D. PRACTICE-BASED LEARNING AND IMPROVEMENT analyze practice experience and perform practice-based improvement activities using a systematic methodology to self-assess one's self for needed improvement locate, appraise, and assimilate evidence from scientific studies related to their patients' health problems obtain and use information about their own population of patients and the larger population from which their patients are drawn by performing appropriate literature searches apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness

4 use information technology to manage information, access on-line medical information; and support their own education facilitate the learning of students and other health care professionals demonstrate independent study habits in the acquisition of clinical and research skills demonstrate life-long learning attitude by attendance and participation at local, regional,and national scientific conferences E. INTERPERSONAL AND COMMUNICATION SKILLS create and sustain a therapeutic and ethically sound relationship with patients use effective listening skills and elicit and provide information using effective nonverbal, explanatory, questioning, and writing skills work effectively with nurses and technical staff as a member or leader of a health care team in rheumatology demonstrate communication skills by presentation and/or participation at local, regional, and national professional scientific conferences F. SYSTEMS-BASED PRACTICE understand how their patient care and other professional practices affect other health care professionals, the health care organization, and the larger society and how these elements of the system affect their own practice know how types of medical practice and delivery systems (HMO, PPO, others) differ from one another, including methods of controlling health care costs and allocating resources practice cost-effective health care and resource allocation that does not compromise quality care advocate for quality patient care and assist patients in dealing with system complexities know how to partner with health care managers and health care providers to assess, coordinate, and improve health care and know how these activities can affect system performance demonstrate knowledge of non-acute provider settings (Rehabilitation, Skilled Nursing, others)

5 G. CLINICAL COMPETENCE IN A VAREITY OF CLINICAL SETTINGS demonstrate proficiency as a consultant and/or leader of a multidisciplinary health care team demonstrate they have mastered those specific research objectives outlined for the fellowship program and have produced sufficient research work to enable them to submit their work for peer-reviewed presentation, scientific meetings, manuscript submissions, or grant applications for research funding III. Methods for Teaching Rheumatology The methods and resources for acquiring the body of knowledge required to become a competent rheumatologist by the end of fellowship will vary depending upon the material and teacher. However, in order to achieve the goals and objectives for the fellowship program the following experiences have been established for the purpose of teaching Rheumatology fellows at the UCHSC. These include: A. INPATIENT RHEUMATOLOGY EXPERIENCE The fellows assigned to this rotation at the University/VA/or Denver Health Medical Centers along with their attending physicians, will be responsible for organizing the teaching activities of the service during that period. This includes the evaluation of inpatient consultations as well as the regular follow-up required while the patient is hospitalized. Essential in this role is the development and refinement of clinical skills. The skills include the ability to construct an appropriate differential diagnosis, assess the patient's needs during hospitalization, develop effective evaluation and treatment plans, and communicate with the referring medical teams. A fellow will need to have the skills to perform literature searches on topics related to patients and will actively participate in educating the consulting team members. Through this experience, the fellow will also develop a comprehensive understanding of the indications, contraindications, techniques, and complications of arthrocentesis as well as the interpretation of results. They will also educate the patient about the procedure and obtain informed consent. Faculty supervision is required in the development of these skills. B. AMBULATORY RHEUMATOLOGY EXPERIENCE All 2 year clinical fellows and 3 year research fellows are required to maintain the equivalent of three half-day continuity clinics and one half-day specialty clinic (when not on University/VA inpatient rotation) each week for the first 12 months of training. The clinical fellow also maintains this clinic schedule the second 12 months of training. The three continuity clinics are one each at the University,

6 Veterans Administration, and Denver Medical Center hospitals. The subspecialty clinics are at the University outpatient facility or National Jewish Medical Center. The three year research fellow has one half-day continuity clinic and one subspecialty clinic a week at University outpatient facility the second 12 months of training and one half day continuity clinic the final 12 months of training. The experience for the fellows will include progressive responsibility throughout the fellowship and will be supervised by attending faculty members. This will enable the fellows to take care of their continuity patients as well as to evaluate new patients. The goal of this experience will be for the fellows to gain expertise in the outpatient evaluation and management of rheumatic diseases. The experience provides an opportunity to develop an understanding for the natural history of these conditions over the course of their fellowship. The diversity of patients seen at the various hospitals will enhance the fellow's experience with different patients with different cultures and resources. It will also enable the fellow to experience health care delivery in different health care systems. C. INTERDISCIPLINARY INTERACTIONS The fellow is provided the opportunity to interact with other disciplines whose expertise is required for the care of patients with rheumatic diseases. These disciplines include, but are not limited to: 1) radiology, 2) pediatric rheumatology, 3) orthopedics, 4) physical medicine, 5) neurology, 6) internal medicine specialties, 7) occupational therapy, 8) dermatology, 9) physical therapy, and 10) pathology. The goal of working with these other specialties is to appreciate the approach to specific conditions that relate to the rheumatic disorders within these departments. These interdisciplinary interactions occur during elective clinical rotations, conferences, lectures, clinics, etc. Clinical electives must be under the supervision of an attending physician in that specialty who participates in creating the educational goals of the rotation. D. DIDACTIC CONFERENCES Conferences are scheduled on regular basis with attendance required of all fellows and divisional faculty. At a minimum there is at least one clinical conference, one basic science conference, one literature review conference (journal club), and one research conference each month. It is encouraged that members from divisions outside rheumatology, including subspecialties outlined in section C, attend the conferences. Fellows must attend a minimum of 80% of conferences. Additionally, fellows are encouraged to attend Medicine Grand Rounds weekly. E. RESEARCH EXPERIENCES An active research component is included within the fellowship training program. A meaningful research experience is provided with protected time for the fellow to pursue their research interests. Exposure to divisional research program is initiated early in the fellowship to allow the fellow adequate insight into the areas

7 of research and select a specific research mentor. The immediate goal of the research experience is for the fellow to learn sound methodology in designing and performing research studies and the correct interpretation and synthesis of research data. During this phase of training the fellow will work under the close guidance of a research mentor. The clinical fellows will have an average of 2 half-days per week to pursue research endeavors, while the research fellows will have 6 half-days per week of dedicated research time during their second and third years. F. CONTINUING MEDICAL EDUCATION AND SOCIETY MEMBERSHIPS In addition to participating in the didactic conferences established within the fellowship program, it is strongly encouraged that fellows become members of the American College of Rheumatology as well as other local organizations that concern themselves with rheumatic illness. Participation in the continuing medical education activities of these professional organizations will help foster the standards of professionalism and augment the process of lifelong learning. Recommended memberships that provide local educational opportunities include the Rocky Mountain Rheumatism Society and the Metabolic Bone Disease Society of Colorado who bring in local and national faculty to give grand rounds or regional seminars. G. EXPERIENCES IN DEVELOPING TEACHING SKILLS The fellowship provides an environment for the fellows that fosters and highly regards teaching activities. This includes not only the education of medical student, physicians, and other allied health care providers, but also patients. Development of these skills requires the fellow to receive instruction and feedback in counseling and communication techniques. Communication techniques should take into account cultural, social, behavioral, and economic concerns. It also addresses ethical topics such as confidentiality and informed consent. H. ADDITIONAL LEARNING OPPORTUNITIES Other opportunities that the fellowship utilizes as a method of instruction for fellows includes self-learning from recommended textbooks and journal articles, ACR reading list,video/audio cassettes, and computer-based activities. Fellows need to develop an attitude of becoming a self-directed and lifelong learner. IV. Methods of Evaluation A. DIRECT OBSERVATION AND EVALUATION The methods for assuring and documenting whether the fellow is gaining the necessary knowledge and experience in rheumatology to meet the core

8 competencies will be assessed through multiple different direct evaluations and observations: 1. Direct observation by teaching faculty -- rheumatologists and other physicians involved in the training of rheumatology fellows will evaluate the fellow through their observation of his/her performance during case presentations, ward rounds, and/or in the laboratory. Monthly evaluations will be done on each fellow and feedback given to those who are not progressing satisfactorily. 2. Procedure log -- the fellow will keep a log of each procedure he/she performs during their fellowship. This will include the identity of the patient, procedure performed, and who staffed the procedure (when applicable). This procedure log will be reviewed at each biannual meeting to assure the fellow is gaining the necessary procedural experience. Fellows are supervised until they are proficient with a procedure. 3. Quizzes -- once a month, a quiz covering a specific subject in rheumatology or immunology will be given. The fellow is expected to study prior to the test which will assess his/her fund of knowledge. Correct and incorrect answers are discussed during the time allotted for the quiz. 4. Quality Improvement Program -- each fellow's patient records are reviewed by the rheumatology staff for accuracy and deficiencies during clinics. 5. In Service Examination - once a year all fellows will take an inservice examination in Rheumatology. Following the examination all questions and answers are discussed. 6. Mini CEX - all fellows will be observed by a faculty member once a year for the following: - History, physical examination, ability to establish rapport, professionalism, ability to communicate, ability to formulate a differential diagnosis and treatment plan 7. Observed Structured Clinical Examination - once a year, all fellows will participate in an OSCE which will cover: - Explanation of a procedure or therapy to a patient - Ability to do infections/aspirations on a cadaver

9 - Ability to examine synovial fluid - Ability to read radiographs - Telephone interaction with a patient - Ability to search the literature and write a letter to a medical director B. FORMATIVE AND SUMMATIVE EVALUATION OF THE FELLOW 1. Formative evaluation of the fellows a. Formal formative evaluations occur at the completion of each rotation where there was a significant interaction with a specific faculty member. For each clinical rotation, the supervising faculty member will complete an evaluation. The evaluation form is the one recommended by the American Board of Internal Medicine and covers the core competencies. All faculty must complete the form prior to the completion of the rotation and review their impressions directly with the fellow. All completed evaluation forms are returned to the Program Director for review and placed in the fellows' permanent file. Completed evaluations are reviewed by the Program Director immediately. Any forms that contain a rating less than satisfactory in any category will require an immediate conference between the fellow and the Program Director to identify causes of poor performance and identify ways to improve the deficiencies. b. During the research phase of training, an evaluation form will be completed by the fellow's faculty mentor. These evaluations are completed every 6 months, reviewed with the fellow by the faculty mentor, and submitted to the Program Director for placement in the permanent file. Completed evaluations are reviewed by the Program Director immediately. Any forms that contain a rating less than satisfactory in any category will require an immediate conference between the fellow and the Program Director to identify causes of poor performance and identify ways to improve the deficiencies. c. All fellows are required to maintain a procedural log that identifies the procedure, date, indication, outcome, complications, and name of supervising physician. A copy of this log will be provided to the Program Director semi-annually for review.

10 d. All fellows are discussed by the Rheumatology Staff who comprise the Education and Evaluation Committee at each monthly staff meeting and a formal report generated. Any deficiencies are immediately relayed by the Program Director to the fellow. e. At least semi-annually, all fellows will confer individually with the Program Director to review all evaluations. This meeting is to provide feedback to the fellows on their performance and to identify areas for professional improvement. A written summary of this session is placed in the fellow's permanent file. This can be reviewed by the fellow at any time. 2. Summative evaluation of the fellow a. At the semi-annual meeting with the Program Director, fellows are provided with feedback on their performance in both a summative and formative fashion. A written summary of the fellows' evaluations is placed in the fellow's permanent file. This evaluation evaluates the fellow based on the ACGME core competencies. It can be reviewed by the fellow any time. b. The overall performance of each fellow is reviewed annually by the Education and Evaluation Committee. This committee monitors the performance of the fellows and assesses their level of competence. This committee determines if a fellow advances to the next year of training and if they graduate. c. Any adverse judgments or evaluations regarding the fellow's level of performance or competence should initially be directed to the Program Director. If the fellow feels that this is not to their satisfaction, then a grievance can be addressed by established institutional policy C. EVALUATION OF FACULTY AND PROGRAM 1. The rheumatology fellow fills out an evaluation sheet on the inpatient rotation, outpatient clinic experience, and attending faculty each month. 2. Each rheumatology fellow fills out an evaluation annually on each faculty member, the value of each rotation, and the value of each conference or educational experience. 3. Each rheumatology fellow fills out an evaluation on the strengths and weakness of the Rheumatology fellowship after they have been out of the fellowship for a year.

11 4. Evaluations on faculty and rotations are collected in a fashion to assure anonymity of the fellow and sent back to the attending physician, Division Head, and Program Director. 5. Fellows are encouraged to maintain a high level of communication with the Program Director and faculty. Periodically, meetings will be established for a formal conference with the fellows and Program Director. These meetings can be used to disseminate information, receive timely feedback, etc. The feedback received during informal meetings, formal meetings, and the semi-annual evaluation form will be used to make programmatic changes.