Basic Sciences

• Anatomy and biology of musculoskeletal tissues, including the embryology, development, biochemistry and metabolism, structure, and function. 
• Immunology including anatomy and cellular eliments of the immune system, immune and inflammatory mechanisms, cellular interactions and immunoregulation, 
• Biomechanics of bones joints and muscles, understand the kinesiology of peripheral and axial joints and gait, and related pathologies
• Neurobiology of pain including peripheral and central mechanisms of nociceptive pathways and processing, mechanisms of action of drugs used for pain, biopsychosocial model of pain,

Clinical Sciences

• Pediatric rheumatic diseases including juvenile rheumatoid arthritis, spondyloarthropathies, psoriasis and other HLA B27 related disorders, Kawasaki disease, lupus erythematosus, mixed connective tissue disease, antiphospholipid syndrome, scleroderma, dermatomyositis/polymyositis, sarcoidosis, Behcet’s disease, Takayasu’s arteritis, Henoch-Schonlein Purpura, Wegener’s granulomatosis, polyarteritis and other vasculitic disorders,
• Infectious/post-infectious arthritis including acute rheumatic fever, Lyme disease, reactive arthritis, and infection triggered autoimmune diseases (Hepatitis C).
• Non-articular rheumatic syndromes including reflex neurovascular/sympathetic dystrophy, myofacial pain syndromes, fibromyalgia and chronic fatigue syndrome,
• Mechanical and acquired musculoskeletal syndromes including osteochondroses, benign tumors, overuse syndromes, infections of bone and joints, osteoporosis, Vitamin deficiencies and secondary osteoarthritis.
• Heritable syndromes associated with musculoskeletal syndromes including skeletal dysplasias, storage diseases, disorders of collagen and connective tissue.
• Autoinflammatory syndromes including familial Mediterranean fever, TRAPS, and CIAIS1 related diseases,
• Malignancies including leukemia, lymphoma, neuroblastoma and other primary or metastatic malignancies of bone and muscle
• Rheumatic aspects in a child who is immunocompromised (congenital or acquired),
• Neonates with consequences of maternal rheumatic disease or medications for rheumatic disease
• Rheumatic aspects of systemic disease, including endocrine, metabolic and gastrointestinal diseases,

,..

Therapeutic modalities and strategies

• Pharmacology for each medication below understanding the dosing, pharmacokinetics, metabolism, mechanism of action, side effects, drug interactions, adherence issues, cost, and use in specific patient populations such as liver or renal dysfunction.  Medications include nonsteroidal anti-inflammatory drugs, glucocorticoids (local and systemic), systemic anti-rheumatic drugs (antimalarials, sulfasalazine, methotrexate, leflunomide, gold compounds, D-penicillamine), cytotoxic agents (cyclophosphamide, chlorambucil, azathioprine), immunomodulatory agents (calcineurin inhibitors, mycophenolate), biologics, gastric protective agents, antihypertensive agents, bisphosphonates, intravenous immunoglobulin,
• Therapeutic procedures including the indications for and potential complications of apheresis
• Physiotherapy and rehabilitation including the indications for exercise therapy, splinting, joint protection, footwear, orthotics,
• Pharmacologic and nonpharmacologic approaches to pain management
• Complementary and alternative therapies including basic principles of acupuncture, massage.

Surgical management

• Bone and joint surgery, understanding the indications for, complications of, pre and postoperative management of total joint replacements, arthroscopy, synovectomies, osteomies, bone biopsies, tendon and soft tissue procedures.

Diagnostic testing

• Laboratory testing, understanding the biologic rationale, methods for performing, and utility/limitations of each test including markers of inflammation, atuoantibodies, immunoglobulins, complement factors, microbial detection (culture, serology and direct viral detection including PCR), HLA typing, flow cytometry for analysis of leukocytes, functional cellular tests, specific genetic tests, relevant hematologic and chemistry testing, urine analysis and urine chemistries.
• Diagnostic imaging understanding the basic underlying principles and technical considerations in the use of radiography, computed tomography, magnetic resonance imaging, ultrasonography, angiography, electromyography, radionuclide scanning, and specialized metabolic and functional imaging
• Pathologic evaluations including indications for, complications of, and principles of interpretation of renal, muscle, skin and vascular tissues
• Synovial fluid analysis including interpretation of cell counts, chemistries

Research Principles

• Principles and methods of epidemiologic and health services research including population statistics, basic biostatistics, outcomes measures (including functional status, quality of life, cost analysis, disease activity and severity),
• Principles of clinical research understanding the limitations and biases in study designs and clinical trials and evidence-based medicine,   
• Laboratory research techniques including understanding the general methodology of serologic techniques, cellular biology, histochemistry, molecular methods, high-throughput techniques, monoclonal antibody production and use and development of animal models.

Bioethics of clinical and basic research

• Principles of informed consent, research integrity, conflict of interest, ethical conduct of research

Methods of acquisition

This fund of knowledge will form the basis for the foundation of understanding the pathogenesis, diagnosis, and management of childhood rheumatic diseases.  The methods and resources for acquiring this knowledge will include, but is not limited to, didactic teaching, case-based teaching, problem-based learning, self-assessment, independent learning from literature and other resources, research experience, attendance at regional and national meetings.

Performance markers

• Basic Science—The fellow should be able to demonstrate understanding of the anatomy, basic immunology, cell biology and metabolism pertaining to the pediatric rheumatic diseases in both didactic and clinical settings.
• Clinical Science—The fellow demonstrates understanding of pathogenesis, epidemiology, clinical expression, treatments and prognosis of the full range of rheumatic and musculoskeletal disease in both didactic and clinical settings.
• Diagnostic Testing—The fellow displays an understanding of the biological and physical basis of the range of diagnostic testing in pediatric rheumatology and the clinical test characteristics of these procedures.
• Research Principles—The fellow should be able to:
• Demonstrate an understanding of the essential components of clinical study design, patient assessment and data analysis
• Exhibit familiarity with the common experimental approaches used in laboratory, clinical and epidemiology research
• Exhibit familiarity with the principles of the ethical conduct of research and the ability to apply these principles in the conduct of their own research during fellowship.

GOAL 2:  Patient Care

The ability to provide quality patient care is the ultimate goal of clinical training in pediatric rheumatology. The fellowship program must require its residents to obtain competence in patient care to the level expected of a new practitioner in this subspecialty. The following defines the specific knowledge, skills, behaviors, and attitudes required, and provide educational specific knowledge, skills, behaviors and attitudes required.

Essential Components of Patient Care

The essence of being a pediatric rheumatologist is the ability to use information derived about a patient (history, physical, laboratory and diagnostic testing) along with medical knowledge to synthesize a differential diagnosis, plan of further evaluation and comprehensive management of the patient.  The specific components include:

Information Gathering

• Obtaining the history
• Performing a careful physical examination
• Obtaining appropriate tests, including laboratory tests, imaging studies, and others

Synthesis of Treatment Plan

Informed medical decision making based on up-to-date scientific information and clinical judgment that also accounts for patient preferences and circumstances.

Implementation of Treatment

• Prescribing medications and rehabilitation
• Patient/family education and counseling
• Preventive medicine and proactive care
• Therapeutic aspiration and injection
• Utilization of allied health care professionals, including those from other disciplines

Reassessment and patient follow up

• Assessment of treatment response
• Recognition of treatment related adverse events

Methods for Acquisition

Learning the essentials of patient care is primarily acquired by caring for patients and their families in the outpatient clinic as well as the inpatient (hospitalized) settings.  These supervised experiences are the focus of clinical training where the trainee observes skilled clinician role models, and participates with the patient and family in the management of their rheumatologic problem.  Situations in which facets of patient care are taught and learned include:

• Didactic teaching - conferences, lectures, or discussions
• Clinical experience in a supervised, mentored clinical setting
• Interactive case-based discussions
• Independent reading - recommended textbooks, journal articles and internet based research and study
• Attendance at regional and national clinical meetings and conferences
• Preparation of patient care portfolios

Performance Markers

• Information Gathering - The fellow should be able to:
• Understand principles and demonstrate competency in obtaining a clinical history, relevant review of systems, and assessing functional status of patients with rheumatic disease symptoms.
• Understand principles and demonstrate competency in performing and interpreting the examination of the structure and function of all axial and peripheral joints, periarticular structures, peripheral nerves and muscles.  Additionally, the fellow should be able to identify extraarticular findings that are associated with specific rheumatic diseases. 
• Understand the indications for and costs of ordering laboratory tests, procedures to establish a diagnosis of rheumatologic disease and of different therapies used in the management of these diseases.
• Understand the principles and interpretation of results of synovial fluid analysis and become proficient in the examination and interpretation of synovial fluid.

• Demonstrate understanding and competency in the assessment and interpretation of:

• Radiographs of normal and diseased joints, bones, periarticular structures and prosthetic joints
• Bone densitometry

• Apply the principles of clinical epidemiology to day-to-day clinical decision making, demonstrating understanding and competency in the indications for and the interpretation of results from laboratory tests and procedures to establish a diagnosis of a rheumatologic disease, including:

• Arthrography, ultrasonography, computed tomography, magnetic resonance imaging of joints, bones and periarticular structures
• Radionuclide scans of  bones and joints 
• Arteriograms (conventional and MRI/MRA) for patients with suspected or confirmed vasculitis
• Computed tomography of lungs and paranasal sinuses
• Magnetic resonance imaging of the central nervous system (brain and spinal cord)
• Electromyograms and nerve conduction studies
• Biopsy specimens including histochemistry and immunofluorescence of tissues relevant to the diagnosis of rheumatic diseases: skin, synovium, muscle, nerve, bone (e.g. metabolic bone disease), minor salivary gland, artery, kidney and lung
• Specific laboratory tests (including, but not limited to) erythrocyte sedimentation rate, C-reactive protein, other acute phase response proteins (e.g. ferritin), rheumatoid factor, anti-cyclical citrillunated peptides,  antinuclear antibodies, anti dsDNA, anti SSA (anti-Ro), anti SSB (anti-La), anti-U1RNP, anti-Sm, anti-topoisomerase I (Scl-70), anti-Jo-1, anti-PM-Scl, antihistone antibodies, antineutrophil cytoplasmic antibodies (including anti-myeloperoxidase and anti-proteinase-3), cryoglobulins, complement component levels, CH50, serum protein electrophoresis, serum immunoglobulin levels, LE preparation, RPR, lupus anticoagulant assays, anticardiolipin and other antiphospholipid antibodies, HLA typing (e.g. HLA-B27), ASO and other streptococcal antibody tests, Lyme serologies, serum and urine uric acid levels, circulating immune complexes, lymphocyte subset and function data, anticellular antibodies (e.g. Coombs’ test, neutrophil antibodies and anti-platelet antibodies), genetic testing for autoinflammatory diseases]
• Arthroscopy

Synthesis of Treatment Plan - The fellow should be able to:

• Demonstrate the ability to construct a differential diagnosis in patients presenting with signs and symptoms related to rheumatologic diseases and to outline further testing necessary to establish the correct diagnosis.
• Demonstrate the ability to construct and implement an appropriate treatment plan for the care of a patient with a rheumatologic problem integrating the prescribing of medications (oral, injectable or infused), counseling, rehabilitative medicine, and, when necessary, surgical or other consultation.  The fellow should be able to explain the rationale and the risks/benefits for the treatment plan.

Implementation of Treatment - The fellow should be able to:

• Demonstrate a working knowledge of clinical pharmacology: for each medication, understand the dosing, pharmacokinetics, metabolism, mechanisms of action, side effects, drug interactions, compliance issues, costs, and use in patients including fertile, lactating, and pregnant women.

• Nonsteroidal anti-inflammatory drugs, COX-2 inhibitors and adequate gastroprotection
• Glucocorticoids: topical, intraarticular, systemic
• Disease modifying antirheumatic drugs:

• historical agents such as gold compounds and penicillamine
• oral agents: methotrexate, antimalarials, sulfasalazine, leflunomide, tetracyclines, auranofin
• parenteral biological response modifiers including inhibitors of TNF, IL-1 and other cytokines and immune based therapies such as CTLA4Ig, anti-CD20, and others developed during their fellowship years

• Cytotoxic drugs: azathioprine, cyclophosphamide, chlorambucil
• Immunomodulators: cyclosporine, FK-506, mycophenolate mofetil
• Antibiotic therapy for septic arthritis, Lyme disease

• Experimental therapies: plasmapheresis, intravenous immunoglobulin, myeloablative therapy and immune reconstitution including stem cell transplantation

• Understand the indications for and demonstrate competence in arthrocentesis.  The fellow should understand the anatomy, precautions (including OSHA requirements) and potential sequelae of arthrocentesis and demonstrate competency in obtaining synovial fluid from diarthrodial joints with adequate informed consent
• Understand the indications for and potential problems with regular childhood and other (e.g., influenza) immunizations in a child with different types of rheumatic diseases, including the risks of live vaccines, the risks of poor immune response to vaccinations.
• Understand the indications and use of therapies aimed at minimizing potential side effects of medications, such as Vitamin D, calcium, bisphosphonates and corticosteroids: mesna, GNRH agonists and cyclophosphamide; folic acid and methotrexate.
• Understand pain assessment and pain management:

• Methods of pain assessment including visual analog scale scores, pain questionnaires
• Non-pharmacological modalities of pain management including exercise, cognitive behavioral therapy
• Pharmacological therapy including:

• Immunosuppressive and anti-inflammatory management of underlying rheumatic disorder.
• Analgesic agents including acetaminophen, nonsteroidal anti-inflammatory agents and narcotic analgesics. 
• Antidepressants
• Investigational uses of approved drugs such as gabapentin 

• Understand changes required in patient management should the rheumatology patient become pregnant; this should include pre-pregnancy counseling about ramifications of becoming pregnant on the disease process, the use of medications before and during pregnancy and in the postpartum period.

• Demonstrate the ability to identify physical impairment; relate the impairment to the observed functional deficits; prescribe appropriate rehabilitation (physical therapy, occupational therapy) to achieve goals to improve the defined impairment
• Understand indications for surgical and orthopedic consultation in acute and chronic rheumatic diseases.
• Pre- and Post-operative Management of the Surgical Patient:

• Understand indications for surgical and orthopedic consultation in acute and chronic rheumatic diseases.
• Understand perioperative evaluation, appropriate referral and medication adjustments.
• Rehabilitation of the rheumatic disease patient after a surgical or orthopedic procedure, as well as aspects of postoperative medical management pertaining to the rheumatologic condition.

• Understand complementary and unconventional medical practices: diet, nutritional supplements, antimicrobials, acupuncture, topical therapeutic agents, homeopathic remedies, venoms, and others.

Reassessment and patient follow up - The fellow should be able to demonstrate the ability to reassess the patient over time, including recognition of treatment related adverse events, and alter the treatment plan accordingly

Evaluation Methods

Faculty performance rating – with regard to patient care
Evaluation committee
Chart review – for patient care, drug prescribing, or outcomes
Objective structured clinical examination (OSCE)
360 evaluations
Portfolio review

GOAL 3:  Practice-based Learning and Improvement

Definition

Essential Components of Practice-based Learning and Improvement

In addition to structured learning of the basic components of medical knowledge and patient care, the rheumatologist must evaluate their knowledge base and care delivery on an ongoing basis with the goal of continually improving that care.  This process includes the following components:

Independent learning
The ability to access and critically appraise appropriate information systems and sources to improve understanding of underlying pathology, assess the accuracy of diagnoses, and gauge appropriateness of therapeutic interventions for the patient population they encounter. 
Self-evaluation of performance
The effective rheumatologist must engage in ongoing self-assessment activities.  This includes the ability to continuously self-evaluate learning needs and to monitor practice behaviors and outcomes to ascertain whether clinical decisions and therapeutic interventions are effective, and adhere to accepted standards of care.
Incorporation of feedback into improvement of clinical activity
The ability to appropriately interpret results of clinical outcome studies, practice data, quality improvement measures, and faculty/peer feedback and evaluations and apply them to patient care and practice behavior.

Methods for Acquisition

Clinical experience in a supervised, mentored clinical setting
Independent reading - recommended textbooks, journal articles and internet based research and study
Faculty-facilitated group discussions and tutorials
Faculty role modeling
Interactive case-based discussions
Systematic chart review of their own patients
Preparation of patient care portfolios
Presentations to peers and lay audiences
Participation in individual or group quality improvement projects

Performance Markers

Independent learning - the fellow should be able to:

• Utilize information technology to search, retrieve, and interpret medical information relevant to the care of patients with rheumatic disease from sources such as:

• Peer-reviewed  clinical journal articles
• Clinical case reports
• Internet-based resources such as Up-To-Date, PubMed, Google
• Clinical performance guidelines published by the ACR and other groups
• Conversations with colleagues and peers
• CME activities including attendance at national and regional meetings

• Critically evaluate and interpret the medical literature using knowledge of clinical study methodology, statistics and methods of health services research.
• Apply learned concepts and conclusions from studies and case reports to the care of individual patients
• Facilitate the learning of students and other health care professionals.

Self-evaluation of performance - the fellow should be able to:

• use a systematic approach, such as a chart review, to analyze own practice and identify learning or practice improvement needs.

Incorporation of feedback into improvement of clinical activity - the fellow should be able to:

• Demonstrate the ability to improve own practice based upon specific feedback and learned concepts.
• Assess the impact of practice improvements on the care of own patients.
• Implement global quality improvement measures in own practice

Evaluation Methods

Faculty performance rating - with regard to demonstration of reflective learning in clinical venues.
Evaluation committee - review of trainee presentations, portfolio-based presentations, and journal article reviews related to practice-based learning and improvement.
Portfolio review - with respect to residents' narratives of critical incidences or other experiences (usually accompanied by reflection on the event), and practice improvement

GOAL 4:  System-based Practice

The increasing complexity and diversity of health care delivery systems presents both challenges and opportunities for the practice of pediatric rheumatology,  Knowledge of the nature and variety of the external and internal systems that can impact clinical practice and the effective utilization of that knowledge to positively impact patient care is an essential skill. Trainee competence in such systems-based practice “…includes an understanding of how their own practices affect others, and knowing how to partner with others to improve health care”.

The knowledge base of systems-based practice comprises the advantages and disadvantages of different health care systems that impact on children with rheumatic diseases. Some of these include the academic system in which rheumatology fellows are training, the various private and public health care delivery systems, the governmental agencies and programs that regulate these systems, the volunteer, private and governmental agencies that are available to educate and assist patients, the public education system, the bureaucracy faced by disabled patients negotiating these systems and the social and economic burden of chronic rheumatic diseases on families.  The goal of the systems-based practice curriculum is to enhance the ability of pediatric rheumatology trainees to positively influence patient care by effectively utilizing these internal and external resources, to serve as effective advocates for their patients, and to provide cost-effective patient care. In some cases this may also mean identifying and organizing change in the local systematic problems that lead to inferior patient care.

These two major aspects of system-based practice (systems knowledge acquisition and systems utilization) are already incorporated in pediatric rheumatology training programs.  The purpose of the systems-based practice curriculum is to clarify the components of systems-based practice, describe how and where the knowledge is acquired, set benchmarks of performance expected of the trainees, and describe the tools used to measure that performance.

Definition

Systems-based practice reflects an understanding 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

Essential Components of System-based Practice

Systems:  a concept of “systems thinking” in health care delivery

This includes an understanding of the limitations and opportunities of various types of rheumatology practices and delivery systems, practice management strategies, managed care and health insurance issues. It also comprises an ongoing analysis of the strengths and weaknesses of the local academic system, in both the inpatient and outpatient settings, and its impact on the health care delivery to rheumatic patients.  In particular, efforts should be made to identify potentially correctable systematic weaknesses and medical errors due to systems failure and to develop strategies to rectify the problems (i.e. Quality Improvement projects)

Partners in health care delivery:  the various providers and resources available to deliver optimal care.

The principal partners in delivering health care to rheumatic patients include providers such as nurses, physiatrists, orthopedists and allied health professionals available within the local healthcare system. Partners also include outside volunteer agencies, both locally and nationally, such as the American College of Rheumatology, the Arthritis Foundation, the American Academy of Pediatrics, the disease-specific foundations (Lupus, Scleroderma, Ankylosing Spondylitis, etc), the National Institute of Arthritis, Musculoskeletal and Skin Diseases (NIAMS) and pharmaceutical companies that have specific patient-related initiatives.  Other agencies that impact on the practice of rheumatology include the American Medical Association (AMA), the Food and Drug Administration (FDA), the Center for Medicare and Medicaid Services (CMS), and the state California Children’s Services.

Advocacy for the patient:  the importance, opportunities and limits of patient advocacy 

This advocacy might consist of assisting patients with applications for California Children’s Services, Medicaid disability, completing preauthorization documents for the use of certain medications and appealing to HMOs with respect to denial of certain treatments, benefits and claims.

Cost-effective health care:  the principles of cost allocation and resource management within the external (state, national) and local systems

This includes a knowledge of the cost and availability of certain drugs (and unavailability of others) on the trainee’s hospital formulary, the mechanisms by which compensation (by CMS and other carriers) is dependent upon the delivery of various levels of service to patients and the methods in place for Quality Review of inpatient and outpatient practice patterns. The utilization of evidence-based cost-conscious strategies for the diagnosis and treatment of patients with rheumatic diseases is important where available.

Methods for Acquisition

Clinical experience in a supervised, mentored clinical setting
Didactic teaching - conferences, lectures, or discussions that highlight particular systems-based practice issues, including multidisciplinary conferences related to individual patients
Faculty-facilitated group discussions and tutorials used to identify systematic problems in patient care delivery
Independent reading specifically related to systems-based practice issues
Preparation of patient care portfolios.  Appropriate portfolio entries might include:

• Documentation of instances of leadership in the multidisciplinary management of complicated patients, of utilization of outside resources for patient care, of patient advocacy.
• Participation in a project to improve the new patient triage system to insure efficient appointment setting.
• Participation in a program to improve tracking system for standard medication toxicity monitoring.
• Developing an outpatient system that would allow patients with acute rheumatic complaints appointments within 24 hrs.
• Outpatient records survey for compliance with evidence-based diagnostic or therapeutic guidelines and development of strategies to correct deficiencies, e.g. laboratory monitoring of patients on DMARDs, PPD testing before TNF antagonists.

Participation in individual or group quality improvement projects

Performance Markers

Systems: The fellow should be able to:

• Demonstrate knowledge about how different health care delivery systems affect the management of patients with pediatric rheumatic diseases.
• Practice management: be familiar with types of practice, equipment, insurance, economics, personnel, ethical aspects, quality assurance, and managed care issues relating to the practice of pediatric rheumatology.
• Identify the strengths and weaknesses of the system in which they are training and practicing. They should also demonstrate the ability to develop strategies to overcome systematic problems they have identified, and/or QI projects to improve it.
• Be familiar with the history of rheumatology, and national organizations such as the American College of Rheumatology, the Arthritis Foundation, and the Association of Rheumatology Health Professionals.
• Understand the influence on rheumatology of the American Medical Association, Food and Drug Administration, California Children’s Services, CMS and other governmental agencies involved in health care legislation, and peer review organizations.

Partners – The fellow should be able to utilize multiple providers and resources as needed for optimal patient care.

• Understand the pediatric rheumatologist’s role as well as when to consult other health professionals (physiatrist, nurse practitioner, visiting nurse, physical therapist, occupational therapist, podiatrist, social worker, vocational rehabilitation counselor, educational specialist, psychologist, others) in the outpatient and inpatient rehabilitation of patients with pediatric rheumatic diseases.
• Demonstrate the ability to educate patients and families about outside resources which might be of assistance to their physical, emotional and financial well being. Examples of these external resources include the Arthritis Foundation juvenile arthritis programs, Lupus Foundation support groups, public education programs, and pharmaceutical company initiated financial aid programs.

Advocacy

• The rheumatology fellow should demonstrate the ability to act as effective advocates for quality care for their patients in a variety of needs, such as dealing with insurance companies and HMO’s, for preauthorizations for medications, filing disability claims, etc.
• The fellow should demonstrate the ability to assist patients in dealing with health system complexities.

Cost effective care

• The fellow should know the local costs of medications they prescribe, rheumatologic lab tests they order and commonly used diagnostic tests and procedures.
• The fellow should demonstrate a commitment to the practice of appropriate evidence-based cost-conscious patient care

Evaluation Methods

Faculty performance rating - with regard to demonstration of effective systems-based performance markers.
An example would be an assessment of the trainee's performance in assembling and leading multidisciplinary health care teams in the management of inpatients (e.g. a complicated SLE patient) and outpatients (e.g. a severe juvenile arthritis patient).  This might involve directing patient management with social work, physical and occupational therapists, nephrology, rehabilitation medicine specialists, orthopedics, and/or pediatrics.

Patient survey - with components that specifically address advocacy issues and cost effective health care delivery.

360 evaluations

Portfolio review - for documentation of systems-based practice performance markers, including QI projects.

Formal written or oral exam – testing for knowledge about system-based practice issues

GOAL 5:  Interpersonal and Communication Skills

Interpersonal and communication skills are essential for the formation of a desirable and effective physician-patient relationship.  The complexity of most of the rheumatic diseases, as well as the increasingly complicated treatment regimens, require a working partnership between patient and physician, and often between physician and the patient's family.  In addition to improved patient satisfaction, confidence and understanding, such working partnerships promote medical compliance.  Effective physician collegial relationships are also dependent upon these skills.

Definition

Interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and other health professionals.

Essential Components of Interpersonal and Communication Skills

Gathering information 

Reliable and effective communication depends upon the availability of accurate and complete information obtained from patients, their family and the complete medical record.  This requires the use of effective listening and communication skills.

Understanding and incorporating patient's and family’s perspective

Such understanding impacts the ability of the physician to appreciate the functional impact of disease and the desire and ability of the patient and their family to be an active partner in the physician’s treatment efforts.

Providing Information

Communication regarding disease causation, diagnosis and treatment is only as effective as the ability of the recipient to understand the information.  Effective explanation therefore requires that the physician communicate in a manner that is understandable to the listener.

Trust

Establishment of trust with patient and patient's family. 

Methods of Acquisition

Clinical experience in a supervised, mentored clinical setting
Faculty role modeling
Independent reading
Faculty-facilitated group discussions and tutorials
Interactive case-based discussions
Systematic chart review of their own patients
Presentations to peers and lay audiences
Participation in quality assurance/improvement initiatives

Performance Markers

Gathering information - the fellow should be able to:

• Use effective verbal, nonverbal, listening, questioning and explanatory skills to obtain a complete and accurate history.
• Obtain properly informed consent.

Understanding and incorporating patient's and family’s perspective - the fellow should be able to:

• Reliably and accurately communicate the patient's and their family's views and concerns to others.
  
• Interact with patients in an empathic and understandable manner

Providing information - the fellow should be able to:

• Write clear and effective consultations in the medical record and in letters to referring physicians.
• Work effectively with colleagues and peers as a member or leader of a health care team.
• Clearly explain benefits and risks of treatment.
• Display effective teaching skills to colleagues and patients.

Trust - the fellow should be able to create and maintain an effective therapeutic and ethically sound relationship with patients over time.

Evaluation Methods

Faculty performance rating – with respect to communication skills and interpersonal relations
Patient/family survey - with components that specifically address trainee’s interpersonal skills
Clinical evaluation exercise (CEX)

GOAL 6: Professionalism

Professionalism is one of the foundations of the practice of medicine and is frequently an inherent character trait in a well-rounded physician. By virtue of their prior medical school and internal medicine training, rheumatology fellows have already attained a substantial level of professionalism, which can be refined during the fellowship training period.  The range of current therapies, including biologic agents, and the complexity of many severe or life threatening rheumatic diseases that require potentially toxic chemotherapeutic agents, place rheumatology trainees in close contact with referring providers, subspecialty consultants, allied health care providers, and hospital and health insurance administrators during the care of their patients. Trainees in many programs also interact with patients from a wide range of cultural and socioeconomic backgrounds.  In addition, fellows are increasingly targeted by the pharmaceutical industry in an attempt to influence prescribing habits at an early phase of their careers. A substantial level of professionalism is thus required to maintain the balance required be an effective rheumatologist.

Definition

Professionalism is manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to patients of diverse backgrounds.

Essential Components of Professionalism

Primacy of patient interest

Placing the interest of the patient before all other external interests is the most fundamental aspect of the medical profession and forms part of the unwritten contract in the patient-physician relationship.  This primacy also implies patient autonomy in the determination of treatment.

Physician autonomy in medical decision making

While an increasing array of bureaucratic, administrative and economic forces continue to limit physician autonomy, some degree of autonomy at the level of medical decision making must be preserved by the physician in order to maintain the primacy of interest.

Physician responsibility and accountability

The practice of medicine incurs responsibility and accountability to:

• Patients/families
  
• Colleagues
• Society
• Self

Humanistic qualities and altruism

Physicians should provide compassionate care and serve all patients and families with respect to their cultural, emotional, spiritual and social needs.

Ethical behavior

This includes being trustworthy and cognizant of conflicts of interest.  Integrity as a physician and consultant rheumatologist must pervade all of the components of professionalism.

Methods for Acquisition

Professionalism can be fostered throughout the fellowship training period beginning with an emphasis on the essential components of professionalism and the specific performance goals at the beginning of the fellowship.

Faculty role modeling.  A culture of professionalism in the training environment is created by mentors, role model clinicians, and a resident culture that demonstrate the values of professionalism and a spirit of collegiality in placing the needs of patients first, maintaining a commitment to scholarship, helping colleagues meet their responsibilities, establishing a commitment to continuous quality improvement, and being responsive to society’s healthcare needs.  A commitment to professional ethics is demonstrated by establishing and maintaining a high standard of moral and ethical behavior within the clinical setting in the care of patients, in the education of residents, in conducting research, and in interacting with medical device and pharmaceutical companies and funding organizations.

Participation in professional activities. Trainees should be given the opportunity to participate in community service, professional organizations, and institutional committee activities.

Clinical experience in a supervised, mentored clinical setting - to provide experiential learning opportunities to observe and practice the key components of professionalism.  Faculty can be encouraged to highlight pertinent professional issues with their fellows at the bedside, at weekly conferences, and in the outpatient clinic setting.

Didactic teaching - conferences, lectures, or discussions devoted to topics of professionalism.  These might also include instructive case conferences using case scenarios to highlight professionalism and ethical issues.

Faculty-facilitated group discussions.  Case vignettes or journal club discussions of issues of professionalism that provide the opportunity for frank discussions between faculty and trainees about these issues.

Independent reading.   Reading assignments of peer reviewed publications and specialty organization publications from the AMA, ABP, AAP, ACGME and web-based discussions on professionalism.

Performance Markers

By the end of their training, fellows should be able to demonstrate competency in the following areas:

Patient Primacy - the fellow should be able to:

• Demonstrate responsiveness to the needs of patients that supercedes self-interest.
• Demonstrate sensitivity and attention to the interests of own patients in formulation of treatment plans.
• Demonstrate the ability to provide autonomy to their patients to decide upon treatment once all treatment options and risks have been outlined for them.
• Provide and obtain key elements of informed consent in an understandable manner for therapeutic interventions and clinical research endeavors.

Physician Autonomy - the fellow should be able to demonstrate independent medical decision-making skill.

Physician accountability and responsibility including:

• Demonstrates timeliness and reliability in clinical care of patients, including completion of medical records and in responding to patient/family calls and requests.
• Reliably follows through on duties and clinical tasks, including timely response to calls from colleagues. Exhibits regular attendance and active participation in divisional and departmental training activities and scholarly endeavors.
• Strives for excellence in care and scholarly activities as a pediatric rheumatologist.
• Works to maintain personal physical and emotional health and demonstrates an understanding of and ability to recognize physician impairment in self and colleagues

Humanistic qualities and altruism

• Exhibits empathy and compassion in physician-patient/family interactions and is sensitive to patient needs for comfort and encouragement.
• Is courteous and respectful in interactions with patients/families, staff and colleagues.
• Treats all patients with respect regardless of race, gender, ethnic, religious or socioeconomic background.
• Provides equitable care to all patients.
• Demonstrates culturally competent care, which is defined here as the ability to deliver effective medical care to patients, regardless of cultural or language differences between the patient/family and the physician.

Ethical behavior

• Demonstrates a commitment to ethical principles relating to provision and withholding of clinical care, confidentiality of patient information and business practices.
• Is trustworthy in following through on clinical questions, laboratory results, and other patient care responsibilities.
• Recognizes and addresses actual and potential conflicts of interest including pharmaceutical industry involvement in their medical education and program funding and guarding against this influencing their current and future prescribing habits.
• Demonstrates integrity in reporting clinical and research findings to supervisors and colleagues.

Evaluation Methods

t is very important to utilize measures that accurately evaluate professionalism. Providing feedback to the fellows will allow constructive or corrective action to be taken in the final phase of their medical education prior to embarking on their career when, although frequently proceeding without any specific supervision, they remain accountable to their patients, society, their peers and themselves.

Faculty performance rating - with regard to demonstration of professional behavior

360 evaluations – regarding professional attitudes and behavior. Fellows may also fill out self-evaluations in the sphere of professionalism and compare it to responses from others for self-reflection and self-improvement.

Portfolio review – which should include a section to include reflective entries on issues of professionalism such as difficult patient and peer encounters, conflicts of interest, and barriers to providing equitable care.

Patient/family survey - with components that specifically address trainee’s professionalism

Adapted from the Core Curriculum Outline for Rheumatology Fellowship Programs: A Competency-Based Guide to Curriculum Development, March 2006. Subcommittee on Training Guidelines of the ACR Committee on Workforce and Training Issues,American College of Rheumatology.

André Barkhuizen, MD,Richard Brasington, Jr., MD, Winn Chatham, MD, David I. Daikh, MD, PhD, Howard Fuchs, MD, Gloria Higgins, MD, Neal Roberts, MD, Arthur Weinstein, MD, Ernesto Zatarain, MD

Rotation

Duration

Training Objective

Pediatric Physical Medicine and Rehabilitation

2 weeks

Understand the indications for pediatric rehabilitation
Gain experience in evaluation of patients,
Understand development of treatment plans,
Gain experience in supervision and collaboration with physical and occupational therapists and other providers for different rehab modalities,
Understand the indications for EMG and NCV and interpretations of results,
Understand the indications for durable medical equipment and bracing/splinting.

Pediatric Pain Service

2 weeks

Gain experience in evaluation of pediatric pain patients, Understand the indications, contraindications, and side-effects of pharmacologic agents for treatment of pain,
Understand  the role of nonpharmacologic treatments for pain in this age group

Pediatric Orthopedics

2 weeks

Recognize common pediatric orthopedic problems including sports injuries,
Understand treatment modalities and options for common orthopedic problems.
Understand the indications, risks and pre and post operative and long term management of total joint replacement in children.

Radiology

2 weeks

Understand the indications for different imaging modalities.
Understand the use and interpretation  of MRI and CT in pediatric musculoskeletal and collagen vascular disease in children
Understand the uses of interventional radiology in pediatric rheumatic diseases
Gain experience in evaluation of results of ultrasound, nuclear medicine imaging in pediatric diseases
Gain expertise in interpretation of plain radiographs in musculoskeletal and collagen vascular disease evaluation.

Laboratory Medicine

2 weeks

Understand the indications, methodology and interpretation of immunologic and serologic tests used in the diagnosis and management of pediatric rheumatic diseases,
Understand the indications, methodology and interpretation of immune competency laboratory evaluations
Understand the indications, methodology and interpretation of hematologic and coagulation laboratory evaluations

Immunodeficiency

4 weeks

Gain experience in the diagnosis and evaluation of congenital and acquired immune deficiencies in childhood
Understand options for management of immune deficiencies in childhood

Pathology

2 weeks

Gain expertise in evaluation of the pathology of rheumatic diseases in childhood with special emphasis will be placed on renal, vascular and skin pathology.

Pediatric Ophthalmology

2 weeks

Gain expertise in the evaluation and differential diagnosis of autoimmune diseases of the eye and systemic diseases with eye manifestations
Understand treatment modalities to treat autoimmune diseases of the eye

Pediatric Rheumatology Curriculum Activity and Evaluation Time line

GOAL 1:  Medical Knowledge

Essential Element of Competency

Month 1-6

Month 6-12

Month 12-18

Month 18-24

Month 24-36

Basic Sciences

Didactic conferences in basic and clinical immunology

Didactic conferences in musculoskeletal anatomy.

Gives third journal club related to research project including basic, clinical, health policy research.

Gives fourth journal club related to research project.

Didactic conferences in cell biology related to autoimmunity and inflammation

Demonstrates understanding anatomy, basic immunology, cell biology and metabolism pertaining to the pediatric rheumatic diseases.

Clinical Sciences and Therapeutic Modalities and Strategies

Introductory lectures on key clinical and diagnostic features of common pediatric diseases.

Disease related modules begin.

Gives first journal club on clinical controversy

Continue didactic disease modules.

Case-based conferences with emphasis on diagnosis and management.

Gives second Journal Club on clinical controversy

Continue didactic disease modules.

Case-based conferences with emphasis on diagnosis and management.

Demonstrates understanding of epidemiology, pathogenesis, clinical expression, treatments and prognosis of the common pediatric rheumatic diseases

Continue didactic disease modules.

Case-based conferences with emphasis on diagnosis and management.

Demonstrates understanding of pathogenesis, epidemiology, clinical expression, treatments and prognosis of the full range of rheumatic and musculoskeletal disease

Continue didactic and case-based conferences.

Gives 2 journal clubs related to research project and clinical controversy related to research project

Diagnostic Testing

Understands the biologic rationale for basic serologic tests for autoimmune diseases, genetic testing for pediatric rheumatic diseases, and markers of inflammatory disease.

Demonstrates an understanding of the role of plain radiographs in juvenile arthritis.

Uses appropriate laboratory testing for evaluation and management of common pediatric diseases.

Demonstrates an understanding of the role of CT and MRI in evaluation of bone, muscle and joint pathology related to common rheumatic diseases

Displays an understanding of the biologic and physical basis of the full range of diagnostic testing including laboratory, MRI, angiography, nuclear medicine, chest CT, electromyography, nerve conduction velocities). and the clinical test characteristics of these procedures.

Demonstrates an understanding of the role and limitations of using evidence-based medicine in  understanding results of diagnostic testing

Research Principles

Didactic conferences in principles of clinical epidemiologic research

Demonstrates an understanding of the essential components of clinical study design, patient assessment and data analysis in journal club and case conferences

Exhibits familiarity with the common experimental approaches used in laboratory, clinical and epidemiology research.

Exhibits familiarity with the principles of the ethical conduct of research and the ability to apply these principles in the conduct of their own research during fellowship.

Pediatric Rheumatology Curriculum Activity and Evaluation Grid

GOAL 2: Patient Care

Essential Element of Competency

Month 1-6

Month 6-12

Month 12-18

Month 18-24

Month 24-36

History taking

Obtain detailed history for joint disorders and specific joints. Obtain detailed history for systemic inflammatory diseases

Organize scenario into rational progression of events emphasizing more important points

Develop/learn lines of questioning allowing more precise history and promoting patient comfort and interaction.

Continue to refine skill in history taking to yield concise accurate review of current problems in the context of entire medical history

Able to teach obtaining history to others, emphasizing important nuances (e.g. severity of stiffness as important as time for JA patients).

Physical examination

Perform/document peripheral joint exam for range of motion, swelling, tenderness; spinal exam for motion and radicular abnormalities.  Describe gait/ overall appearance.  Describe nature of skin rashes.

Identify effusions, synovial proliferation, specific patterns of joint involvement, vasculitis signs/symptoms and extraarticular findings of rheumatologic disorders

Perform quantitative peripheral and axial joint assessment, skill in muscle testing and ophthalmoscopic exam

Able to teach physical examination skills to others.

Able to grade improvement or worsening of musculoskeletal examination

Elicits subtle findings with confidence

.

Laboratory investigation

Have specific reasons for ordering any laboratory test, understanding the cost of tests ordered

Understand principles of laboratory monitoring.  Review all studies ordered.

Understand nature of RF, anti-CCP, ANCA, acute phase reactants. 

Understand nature of ANA subsets, immune testing, complement assays and other tests ordered. 

Understand predictive values of tests as ordered.

Understand rheumatologic indications for renal, brain, lung, skin, nerve, artery, synovium, bone, parotid and liver biopsy

.Review testing to assure validity (e.g. be able to reasonably review findings with pathologist).  Able to teach others salient histologic features of rheumatologic disorders.

Diagnostic imaging

Orders must include adequate useful clinical information. Understand cost of study ordered

Review available studies, identify features of repair, inflammation or infection.  Understand indications for angiography

Develop differential diagnosis of imaging findings.  Distinguish inflammatory vs non-inflammatory findings

Able to teach others salient features of differential diagnosis of imaging findings..

Medical record review

Compile complete and orderly reviews with pertinent history, previous testing and medical opinions compliant with CMS billing requirements

Attempt to receive complete information from previous providers.

Assign relative quality to information and assemble in a meaningful manner

Differential diagnosis

Determine if a focal or systemic problem; inflammatory vs noninflammatory.

Learn meaning of classification criteria for JIA, SLE, JDM and other conditions.  

Be able to diagnose JIA, SLE, JDM, and noninflammatory musculoskeletal pain syndromes.

Develop organized, prioritized differential diagnoses in the context of the history, testing, and physical examination.

Develop differential diagnosis of specific joint findings (e.g. discern spondyloarthropathy from oligoarticular JIA; different types of vasculitis)

Be able to discern non-rheumatologic problems in patients with rheumatologic diseases.  Be able to run patient care conference discussions of differential diagnosis

Treatment plan and documentation

Understand toxicities of therapies chosen.  Appropriate use of immunotherapy, NSAIDs, osteoporosis agents, steroids, physical medicine.

Referral letters should detail the above. Document elements necessary to fulfill CMS guidelines for billing purposes

 Adequately discuss risk/ benefit of treatment options to patients and families and document in records.

Understand current  treatment guidelines for major pediatric rheumatic diseases.

Discuss in more depth the management options with patients and families.  QA/QI to assess if benchmarks accomplished (e.g. osteoporosis prevention/management for patients on steroids)

Provides referral letter  that is concise, instructive (educational) and outline treatment options and rationale for option chosen.

Demonstrate understanding of the evidence-base medicine for the treatment of pediatric rheumatic diseases

.Develops a comprehensive treatment plan for spectrum of pediatric rheumatic diseases, including ongoing  evaluation of progress, and plans for change in treatment plan if needed

Joint aspiration and injection

Demonstrate competence in sterile technique and universal precautions

Understand indications for joint aspiration and/or injection

Write a procedure note

Able to aspirate/inject knees, wrists and ankles independently.

Understand differences in intraarticular medications.   Appropriate post-injection care (splinting, etc)

Able to aspirate/inject joints with deformity and digits, elbows independently.

Able to demonstrate to others joint aspiration techniques and synovial fluid analysis

Reassessment and follow up

Demonstrate due diligence

Determine when patient will need to return for follow up (for toxicity monitoring and/ or disease monitoring)

Appropriate toxicity monitoring . 

Ability to discern change in status  from previous

Continue applying differential diagnosis to patient situation to assure correct course being taken.  Use information previously obtained to refine encounter (to correct data or promote more efficient encounter)

Understand the evolving nature of the disease including physical findings, morbidity, comorbidity.  Incorporate assessment tools into practice as appropriate

Be able to develop possible alternative treatment plans for one or two encounters in future.

Be able to develop comprehensive treatment plans for patients with serious disease that have failed standard therapies.

Pediatric Rheumatology Curriculum Activity and Evaluation Grid

GOAL 3: Practice-Based Learning and Improvement

Essential Element of Competency

Month 1-6

Month 7-12

Month 13-18

Month 19-24

Month 25-36

Accessing information to affect independent learning and practice improvement.

Maintain clinical portfolio of instructive cases including case-directed review of current medical literature.

Obtain QI data on continuity clinic practice

Maintain clinical portfolio of instructive cases

Obtain QI data on continuity clinic practice

Maintain clinical portfolio of instructive cases

Obtain QI data on continuity clinic practice

Maintain clinical portfolio of instructive cases

Obtain QI data on continuity clinic practice

Maintain clinical portfolio of instructive cases

Self-evaluation of performance

Maintain clinical portfolio of instructive cases

Evaluate QI data

Maintain clinical portfolio of instructive cases

Evaluate QI data, assess improvements and/or ongoing deficiencies

Maintain clinical portfolio of instructive cases

Evaluate QI data, assess improvements and/or ongoing deficiencies

Evaluate QI data, assess improvements and/or ongoing deficiencies

Incorporation of self-assessment data and feedback into improvement of clinical practice

Maintain clinical portfolio of instructive cases

Implement plans to improve practice based on QI data assessment

Maintain clinical portfolio of instructive cases

Implement plans to improve practice based on QI data assessment

Maintain clinical portfolio of instructive cases

Implement plans to improve practice based on QI data assessment

Critically reevaluate current clinical guidelines/pathways

Maintain clinical portfolio of instructive cases

Implement plans to improve practice based on QI data assessment

Critically reevaluate current clinical guidelines/pathways

Maintain clinical portfolio of instructive cases

Pediatric Rheumatology Curriculum Activity and Evaluation Grid

GOAL 4: Systems - Based Practice

Essential Element of Competency

Month 1-6

Month 7-12

Month 13-18

Month 19-24

Month 25-36

Systems Thinking

external and internal

QI project (s)

Learns of national and local systems through introductory didactic sessions, self-directed learning and supervised clinical experience

Analyses strengths and weakness of local health system and presents

these at divisional

meetings

Able to identify one problem area potentially amenable to improvement and design a QI project

Conducts QI project, including obtaining IRB approval if needed

Presents results of QI project, documents systems issues in portfolio

Partners in Health Care Delivery

local and national resources

Learns of national and local resources through introductory didactic sessions, self-directed learning and supervised clinical experience

Interacts with local partners (subspecialists, residents, hospitalists, physical and occupational therapy, social work)

Able to coordinate multidisciplinary approach to care of patients

Identify and utilize disease - specific partners (AF, ACR, AAP, CARRA), interacts with local foundations

Team leadership in provision of multidisciplinary care documented in portfolio, 360 evaluation

Advocacy for the Patient

in dealing with the local medical systems

Learns of the systems issues facing the child and adolescent with rheumatic disease in local institution through supervised clinical experience

Able to obtain preauthorizations for medications and procedures.

Able to assist patient’s families in understanding and utilizing medical insurance, both private and state/federal

Assists patients and families in obtaining financial aid for medications, orthotics when needed and possible

Advocacy documented in portfolio, patient surveys, 360 evaluation

Cost-Effective Health Care

knowledge and application

Understands the various health care financing options for children.

Learns of methodology of cost effective analysis through didactic sessions and self directed learning, can discuss journal articles on this topic

Understands the local costs of diagnostic services and rheumatic medications

Practices cost -conscious patient care based on evidence

Cost-conscious patient care documented in global assessment,  patient surveys

Pediatric Rheumatology Curriculum Activity and Evaluation Grid

GOAL 5: Interpersonal Communications

Essential Element of Competency

Month 1-6

Month 7-12

Month 13-18

Month 19-24

Month 25-36

Gathers Information from patients, family and colleagues

Provides patient and family information for informed consent for common medications and DMARDS

Seeks and incorporates feedback from evaluations by faculty

Seeks and incorporates feedback from faculty, patient/family and 360 evaluations

Seeks and incorporates feedback from faculty, patient/family and 360 evaluations

Seeks and incorporates feedback from faculty, patient/family and 360 evaluations

Understands and incorporates the patient’s perspective

Demonstrates diversity sensitivity according to University guidelines

Demonstrates understanding and sensitivity to patient/family issues with adherence, denial, anxiety

Faculty, family and social services feedback of trainee’s interaction with patient and family

Faculty, family and social services feedback of family conference led by trainee

Provides Information to patients, family and colleagues

Able to discuss costs and benefit of all JIA DMARDs.

Provides accurate sign-outs

Writes effective consultations, letters and referrals

Able to discuss cost-benefit of all lupus nephritis treatments.

Resident lectures (2)

Takes leadership role with attending support on inpatient rounding

Faculty and social services feedback of family conference led by trainee

One observed death and dying family meeting

Faculty, family and social services feedback of family conference led by trainee

Participates in death and dying family meeting

Trust. Establish trust with patient and patient's family.

Clearly describes risks and benefits of therapeutic interventions and procedures.

Demonstrates commitment to ongoing care for patient cohort

Favorable letters or other unsolicited feedback

Favorable rating in Patient Surveys

Able to maintain a sound relationship with patients over time

Functions as a Team Member Serves as both a member and leader of a health care team

Uses interpreters and allied health professionals appropriately

Effectively interacts and communicates with colleagues, peers, and team members.

Demonstrates commitment to being team member

360 evaluation

Demonstrate the ability to effectively teach patients and colleagues.

Participates in divisional retreats.

Incorporates feed back from 360 evaluation

Identifies and implements QI/QA initiatives to enhance team functioning.

Participates in committee work outside the division.

Effectively interacts and communicates with colleagues and peers—Incorporates feedback from 360 degree evaluation

Pediatric Rheumatology Curriculum Activity and Evaluation Grid

GOAL 6:  Professionalism

ssential Element of Competency

Month 1-6

Month 6-12

Month 12-18

Month 18-24

Month 25-36

Primacy of patient interest

Demonstrate sensitivity and attention to the interest of patients in formulating treatment plans

Demonstrate ability to obtain informed consent for procedures and treatment regimens

Demonstrate ability to provide autonomy to patients and families in complex treatment decisions

Demonstrate ability to resolve conflicts between patient/family interests and interests of the trainee or health care team

Physician autonomy in medical decision making

Recognize bureaucratic, administrative and economic forces affecting physician autonomy

Demonstrate ability to work within the clinical training environment to make treatment decision for patients

Demonstrate ability to effectively advocate for patients to receive effective care despite expense and other administrative barriers

Physician responsibility and accountability

Demonstrate timeliness and reliability in clinical care of patients

Reliably follow through on duties and clinical tasks. Attend and participate in divisional and institutional training and scholarly activities

Demonstrate willingness to strive for excellence in care and scholarly activities

Maintain personal physical and emotional health. Recognize and act upon physician impairment in self and others

Demonstrate understanding of the  depth of physician responsibility and accountability as an attending physician

Humanistic qualities and altruism

Exhibits empathy and compassion in physician-patient interactions

Demonstrate respect for all patients regardless of race, gender and socio-economic background

Demonstrate courtesy and respect in interactions with patients and staff

Provides equitable care to all patients

Demonstrate willingness to work with patients and families with difficult psychosocial challenges

Volunteer for the AF, Lupus Foundation or other patient service and  advocacy group

Ethical behavior

Demonstrate trustworthiness in following through on patient care responsibilities

Demonstrate integrity in reporting clinical and research findings to supervisors

Recognize actual and potential conflicts of interest in pharmaceutical funding of medical education

Address actual and potential conflicts of interest in pharmaceutical funding of medical education

Demonstrate understanding of biomedical ethics, and apply to resolving ethical conflicts