Student/Resident Rotation on Rheumatology
Anne Miller, MD
Sriya Ranatunga, MD, MPH
Krati Chauhan, MD, MPH
The principal goal of your rheumatology rotation is to learn an approach to the diagnosis and management of patients with a variety of rheumatic disorders that will help you in your own practice of medicine. Learning this will also prepare you for your board exam in internal medicine. Please let us know if you have any special interests you would like to cover during this rotation.
The Outpatient Clinic
You will encounter rheumatic disorders most frequently in the outpatient setting, so your outpatient experience is frankly more important than inpatient consults. Please try not to schedule other activities during these clinics. If you cannot attend an outpatient clinic, please let us know as soon as possible; we may need to adjust the patient schedule. If conflicts arise (an unexpected lecture, a tour for resident applicants, etc.), we will leave it to your judgment what is in your best interest to do, but let us know what you are doing.
Our intention is to have you evaluate patients independently, particularly new patients. After you present the patient to us, we will then re-evaluate the patient with a more focused history and physical. This will allow you to make a comparison between our approaches and will give you the opportunity to get immediate feedback on your musculoskeletal exam. Finally, the re-examination reassures patients that we indeed understand their history and have first-hand knowledge of their exam.
PLEASE ARRIVE AT CLINIC 5-10 MINUTES BEFORE THE CLINIC START TIME so you can review the patients’ medical records and start promptly with the first patient. When possible, we will introduce you to the patient, but start without this introduction if we are not quickly available. As much as humanly possible, we want to see patients on time. Particularly for new patients, please leave the patient’s old records out of the patient’s room, so we can examine them while you examine the patient.
For new patients, please do a thorough history and physical exam. When possible, try to complete this within 30 minutes and present it to us in less than 5 minutes. Please record your H&P in Centricity with the assessment and plan; we will go through it and give you feed back.
For follow-up patients, you should generally be more focused and concentrate on what has happened since we last saw them. This can typically be done in less than 10 minutes. Summarize any labs or other diagnostic tests we previously ordered. Please record your H&P on the rheumatology template. For both new and follow-up patients, it is particularly important for you to record the diagnosis and treatment plan; we will use this information when we finalize our consultation note.
DURING THE CLINIC, THE PATIENT IS THE NUMBER ONE PRIORITY. We will provide teaching during the clinic, but if we fall behind and cannot discuss your questions in the clinic, please bring them up for discussion during our teaching sessions or after we finish clinic.
In general, we have found that more than two trainees per attending in the clinic can lead to inefficient use of trainee time. Thus, if there are three or more residents and students on the service, we sometimes split the clinics among you to maintain optimal learning while you are in the clinic. THIS DECISION WILL BE MADE ON A CLINIC BY CLINIC BASIS. When not in the clinic, you will be able to work on the inpatient consult service, read the core material in rheumatology, prepare for journal club or your literature topic review (if assigned), review the slide series in rheumatology, etc.
In rheumatology, we are involved in a number of quality improvement projects. Please become familiar with them, understand their importance, and participate in them. In addition to this, please act as a safeguard for the patient. Please double check to make sure we have done everything we set out to do in our discussion (all the labs are ordered, prescriptions written, etc.). Please make sure all patients on prednisone and essentially all post-menopausal women have had a determination of their bone mineral density. Please also make sure that any pre-menopausal women on DMARDs have been counseled about prevention of pregnancy. We are also working to provide immunization to immunosuppressed patients.
We will call or page you when there is an inpatient consult. When you get a consult, for everyone’s sake, please evaluate the patient as soon as possible. We can rearrange the teaching times for this purpose. Following the consult, you will dictate a summary, discuss the case with the team requesting the consult, and serve as a communication liaison.
The primary procedures in rheumatology are joint aspirations and injections as well as injections of tendons and bursae. Performing these procedures is not a primary goal of this rotation; understanding when and when not to perform these procedures is a primary goal. We have knee and shoulder models residents can use to practice these techniques, and all appropriate efforts will be made to involve prepared residents in aspiration and injection of patients. Typically, this is more easily accomplished on inpatients than outpatients. If one of your GIM clinic patients needs to have a joint aspiration or injection, you can talk with one of the rheumatologists to supervise you in this procedure.
You are expected to read the PRIMER ON THE RHEUMATIC DISEASES during the rotation. We cannot emphasize the importance of this enough. If you know the PRIMER, you will be in good position to take good care of your patients and to do well on the boards. You should read the PRIMER one other time before your board exam. For all of these reasons, we recommend that residents, particularly residents pursuing primary care, own a copy of the PRIMER. There is nothing sacred about the PRIMER, however. You can pick another source; what is important is that you read from a reputable text. A review of multiple choice questions should supplement, not replace, the reading of a text.
You are also expected to read in more depth on problems your patients have. We have enclosed a list of other resources you can use in addition to the primary literature.
Teaching sessions will involve these activities:
CLINIC WRAP-UP. While we will discuss teaching points during clinic, there will be times when we do not have time for discussions in the clinic. If you have questions about your clinic patients that we did not have a chance to address in the clinic, please bring them up at the start of our teaching sessions with the appropriate rheumatology faculty. Similarly, we will try to make teaching points that we did not have a chance to discuss during clinic.
CORE SEMINARS. In this series we will cover the core material you need to know about rheumatology. We have attached a list of key subject areas along with the teaching session times. These sessions are meant to be interactive teaching forums, not lectures. To get the maximum benefit from these sessions, you are expected to read the assigned sections of the PRIMER before the teaching session. We will then discuss the material. We will ask you questions; you can ask us questions. While we will certainly get an impression of your fund of knowledge and your preparation for the session, the primary goals of this format are to:
- Adjust the discussion according to your knowledge level.
- Keep everyone awake.
- Improve long term knowledge. Studies indicate that you are more likely to remember material discussed in this manner rather than passively hearing the same information.
- Keep learning fun.
- Provide incentive to read the material.
While there will be exceptions to most every teaching point we discuss, we will focus on the generalities, unless we are sure the fundamentals are already firmly grasped.
JOURNAL CLUB (IF ASSIGNED): Residents and students will present a journal article to their colleagues. You should pick a research article with data (not a review) pertaining to rheumatology published in the last 2-3 months, preferably based on a patient you evaluated. The best sources are typically NEJM, Annals of Internal Medicine, Lancet and Arthritis and Rheumatism. Check with Dr. Ranatunga to make sure the article is appropriate.
Please bring a copy of the article for everyone and make your presentations brief (approximately 5 minutes). State the hypothesis of the article and the experimental design without reading the entire list of inclusion and exclusion criteria (please). Review the main findings by examining the relevant figures or tables. Briefly discuss the merits and drawbacks of the work. We will then discuss the article and its implications.
LITERATURE REVIEW SESSION (IF ASSIGNED): Once a month, toward the end of the rotation, residents and students will be asked to present a focused topic review to their colleagues and the faculty. The topic would be based on a rheumatologic issue in one of your patients. The topic needs to be approved by Dr. Miller and needs to be focused: for example, a review of the neurologic manifestations of lupus is too broad; whether Plaquenil improves depression in lupus patients is a more focused and doable topic.
You need to review 3-4 articles, only one of which can be a review article. You need not use slides. Presentations need to be less than 15 minutes. This presentation can occur at the end of a teaching session or during unscheduled time as arranged with the other trainees (with faculty present as able).
At the end of the rotation, we will sit down and review the rotation. We want this rotation to meet your needs, so we need your feedback and advice to achieve this goal. We have indeed made a number of changes based on previous feedback. Within the last week of your rotation, be sure to set up a meeting with Dr. Miller/Dr. Ranatunga so that she can give you face-to-face feedback.
Rheumatology evaluation form includes all of the six competencies. Residents are expected to read this evaluation form at the start of the rotation and to make sure that they demonstrate these competencies during their rotation. The rheumatology faculty will meet at the end of the rotation to discuss the progress of each resident and to give a comprehensive evaluation that represents input of all the attending physicians. We will also elicit the input of nurses, patients, and others involved with you during the service. The critical issues are in what we tell you and in the comments that we write, not the summary score. Unless we state otherwise, the comments and scores pertain to rheumatology (your rheumatology fund of knowledge, your clinical judgment in managing rheumatic disorders, etc).
Teaching Sessions in Rheumatology
Teaching sessions will cover the core curriculum in rheumatology. They are not meant to be didactic teaching sessions. They are meant to be interactive, with the attending asking a number of questions about the topic. Thus, it is extremely important that residents read about the topic prior to the session itself. To properly prepare for these sessions, it is important that the residents work together with the medical students on the rotation to coordinate the topic to be discussed with sufficient time to allow everyone to read about the topic before the teaching session.
While the required reading is from the Primer on the Rheumatic Diseases, reading similar material from other sources is permissible. Residents are responsible for all of the listed reading. Students are encouraged to read all of the sections but are required to read those that are underlined. While not assigned to a particular topic, Chapters 2-3 need to be read by everyone early in the rotation.
While other topics can be discussed if there is time, here is what we consider the core material to cover:
Topic Chapters in Primer 13th Edition
Overview 2A-C, 2D, 3A-B, 40
Rheumatoid Arthritis 4, 6, 23
Gout 12, 13
Scleroderma / Raynaud’s 17
Spondyloarthropathies 3C, 8, 9, 10
Vasculitis 21A-C, 21D-F, 42
Osteoarthritis 11, 36, 41
SLE 15, 16
Rheumatology Clinic Schedules
8:30 AM – 12:30 PM Drs. Miller, Ranatunga, and Chauhan
9:00 AM – 12:30 PM Drs. Miller, Ranatunga, and Chauhan
8:30 AM – 12:30 PM Drs. Miller and Ranatunga
1:00 PM – 4:30 PM Dr. Ranatunga
8:30 AM – 12:30 PM Drs. Miller and Chauhan
1:00 PM – 4:30 PM Drs. Miller and Chauhan
8:30 AM – 12:30 PM Drs. Ranatunga and Chauhan
All times may vary because of patient scheduling.
All rheumatology clinics are held in the medicine clinic which is located on the second floor of the SIU Clinics Building (751 N. Rutledge) Room 2300.
Resources in Rheumatology
The major knowledge base resource in rheumatology is the Primer on the Rheumatic Diseases. You should read this text twice before your board exam. There is ample time to accomplish this meager goal. Please make this a priority during your rotation. You can, of course, choose another source to read. Board review questions should supplement, not replace, the core reading. It is a good idea to bring reading material to the clinic in case there are down times. Though residents are encouraged to purchase their own copy of the primer for future reference, copies of the primer are available through the rheumatology secretary Amy Gronewald. The SIU Medical School library has the primer on reserve at the circulation desk and it is available to both residents and students.
For access to electronic version of the Primer on the Rheumatic Diseases
SIU main web page, http://www.siumed.edu/
Select from top bar items: Research
Select from left hand column: Medical Library
In the middle of the screen, in the search box:
Type: Primer on the Rheumatic Diseases
Choose (from dropdown): Title
Select: Primer with copyright 2008
Scroll down to: item with Location: Springer Medicine eBook Collection
Click: “SpringerLink” hyperlink
Electronic version of Primer will be displayed.
The following power point summaries are available on the American College of Rheumatology website and are encouraged:
Top Bar - Education & Careers
Left Bar – Resources & Tools
Select – High Impact Rheumatology
Click – Accept
Attn: When It Really Hurts
Evaluation and Management of Rheumatoid Arthritis
Multisystem Inflammatory Disease
Rheumatology At A Glance
Other sources are available in Dr. Miller’s office; please let Amy know if you borrow any of them:
- ACR Rheumatology Core Curriculum Slide Series. 26 cases with questions and answers keyed to slides. Sides are arranged in order on three carousels with a question and answer book. Lots of physical exam findings. Donated by the SIU Alumni Association. We also have a CD version.
- Brower’s Arthritis in Black and White. Best introductory text on X-rays in rheumatology. Short.
- MKSAP reviews and questions and answers.
- Hunder’s Atlas of Rheumatology for clinical exam findings.
- CDs. We have some CD presentations that include the ACR Core Curriculum Slide Series as well as programs on high impact rheumatology, osteoporosis, etc. that you can review.
- Knee and Shoulder Joint Models. With supervision, these can be used to practice injection techniques. Donated by the SIU Alumni Association.