Rheumatology Curriculum

Rationale:

APPENDIX DIAGNOSTIC DECISION-MAKING

Physicians are responsible for directing and conducting the diagnostic evaluation of a broad range of patients, including patients seeking advice on prevention of and screening for disease and patients with acute and chronic rheumatologic illnesses. In a time of rapidly proliferating tests, medical students must learn how to design safe, expeditious, and cost-effective diagnostic evaluations. This requires well- developed diagnostic decision-making skills that incorporate probability-based thinking.

Specific learning objectives:

1. Knowledge: Students should be able to define, describe, and discuss:
   1. Key history and physical examination findings pertinent to the differential diagnosis. (MK,OPP))
   2. Information resources for determining diagnostic options for patients with common and uncommon rheumatologic problems. (MK, PLI)
   3. How critical pathways or practice guidelines can be used to guide diagnostic test ordering.(MK)
2. Skills: Students should demonstrate specific skills, including:
   1. Identifying problems with which a patient presents, appropriately synthesizing these intological clinical syndromes. (PC)
   2. Identifying which problems are of highest priority. (PC)
   3. Formulating a differential diagnosis based on the findings from the history and physicalexamination. (PC, OPP))
   4. Using the differential diagnosis to help guide diagnostic test ordering and sequencing. (PC)
3. Attitudes and professional behaviors: Students should be able to:
   1. Seek feedback regularly regarding diagnostic decision-making and respond appropriately (P) 2. Recognize the importance of and demonstrate a commitment to the utilization of other healthcare professionals in diagnostic decision making. (P, SBP)

Rationale:

CASE PRESENTATION SKILLS

Communicating patient care information to colleagues and other health care professionals is an essential skill regardless of specialty. Students should develop facility with different types of case presentations: written and oral, new patient and follow-up, inpatient and outpatient.

Specific learning objectives:

1. Knowledge: Students should be able to define, describe, and discuss components of comprehensive and abbreviated case presentations (oral and written) and settings appropriate for each. (MK)
2. Skills: Students should be able to demonstrate specific skills, including:
   1. Prepare legible, comprehensive, and focused new patient workups that include the followingfeatures as clinically appropriate:
      • Concise history of the present illness organized chronologically with minimal repetition,omission, or extraneous information, and including pertinent positives and negatives.(PC, CS)
      • A comprehensive physical examination with detail pertinent to the patient’s problem. (PC, CS, OPP)
      • A succinct, prioritized, and, where appropriate, complete list of all problems identified by the history and physical examination. (PC, CS, OPP)
      • A differential diagnosis for each problem (appropriate for the student’s level of training. (PC, CS)
      • A diagnostic and treatment plan for each problem (appropriate for the student’s level of training). (PC, CS, OPP)
   2. Orally present a new or followup inpatient’s or outpatient’s case in a logical manner, chronologically developing the present illness, summarizing the pertinent positive and negative findings as well as the differential diagnosis and plans for further testing and treatment. (PC, CS)
3. Attitudes and professional behaviors: Students should be able to:

Demonstrate ongoing commitment to improving case presentation skills by regularly seeking feedback on presentations. (PLI, P)
Accurately and objectively record and present all data. (P)

Rationale:

HISTORY-TAKING AND PHYSICAL EXAMINATION

The ability to obtain an accurate medical history and carefully perform a physical examination is fundamental to providing comprehensive care to adult patients. In particular, the internist must be thorough and efficient in obtaining a history and performing a physical examination in patients with a wide variety of acute and chronic rheumatologic problems. The optimal selection of diagnostic tests, choice of treatment, and use of subspecialists, as well as the physician’s relationship and rapport with patients, all depend on well-developed history-taking and physical diagnosis skills.

Specific learning objectives:

1. Knowledge: Students should be able to define, describe, and discuss:
   1. The significant attributes of a symptom, including: location and radiation, intensity, quality,temporal sequence (onset, duration, frequency), alleviating factors, aggravating factors, setting, associated symptoms, functional impairment, and patient’s interpretation of symptom. (MK, OPP)
   2. The four methods of physical examination (inspection, palpation, percussion, and auscultation), including where and when to use them, their purposes, and the findings they elicit. (MK, OPP)
   3. The physiologic mechanisms that explain key findings in the history and physical exam. (MK, OPP)
   4. The diagnostic value of the history and physical examination. (MK, OPP)
2. Skills: Students should be able to demonstrate specific skills, including:
   1. Using language appropriate for each patient. (PC, CS)
   2. Eliciting the patient’s chief complaint as well as a complete list of the patient’s concerns.(PC, CS)3. Obtaining a patient’s history in a logical, organized, and thorough manner, covering the history of present illness; past medical history, preventive health measures, social, family, and occupational history, and review of systems.4. Demonstrating proper hygienic practices whenever examining a patient. (PC)
   5. Performing a physical examination for a patient in a logical, organized, respectful, and thorough manner, giving attention to the patient’s general appearance, vital signs, and pertinent body regions. (PC)
3. Attitudes and professional behaviors: Students should be able to:
   1. Recognize the essential contribution of a pertinent history and physical examination topatient care. (P)
   2. Establish a habit of updating historical information and repeating important parts of thephysical examination during follow-up visits. (P)
   3. Demonstrate consideration for the patient’s feelings, limitations, and cultural and socialbackground whenever taking a history and performing a physical exam.(P)

Rationale:

INTERPRETATION OF CLINICAL INFORMATION

In the routine course of clinical practice, most physicians are required to order and interpret a wide variety of diagnostic tests and procedures. Determining how these test results will influence clinical decision making and communicating this information to patients in a timely and effective manner are core clinical skills that third-year medical students should possess.

Specific learning objectives:

A. Knowledge: Students should be able to:

1. Interpret specific diagnostic tests and procedures that are ordered to evaluate patients whopresent with common symptoms and diagnoses encountered in the practice ofrheumatology. (PC, MK)
2. Take into account the important differential diagnostic considerations, including potentialdiagnostic emergencies. (PC, MK)
3. Define and describe for the tests and procedures listed:• Indications for testing. (PC, MK)• Critical values that require immediate attention. (PC, MK)
4. Independently interpret the results of the following laboratory tests:

• CBC, ANA, extractable nuclear antigens,anti-double stranded DNA, rheumatoid factor, erythrocyte sedimentation rate, complement, human leukocyte antigens (B-27, DR-4, etc), serum iron, TIBC, ferritin, transferrin, UA, electrolytes, BUN/Cr, glucose, hepatic function panel, uric acid, synovial fluid analysis (PC, MK)

2. Skills: Students should be able to demonstrate specific skills, including:
   Recording the results of laboratory tests in an organized manner, using flow sheets when appropriate. (PC)
3. Attitudes and professional behaviors: Students should be able to:

Appreciate the importance of follow-up on all diagnostic tests and procedures and timely communication of information to patients and appropriate team members. (P) Personally review medical imaging and laboratoty studies to assess the accuracy and significance of the results. (P)

Rationale:

THERAPEUTIC DECISION-MAKING

Internists are responsible for directing and coordinating the therapeutic management of patients with a wide variety of problems, including critically ill patients with rheumatologic diseases. To manage patients effectively, physicians need basic therapeutic decision-making skills that incorporate both pathophysiologic reasoning and evidence-based knowledge.

Specific learning objectives:

1. Knowledge: Students should be able to define, describe, and discuss:
   1. Information resources for determining medical and surgical treatment options for patientswith common and uncommon rheumatologic diseases. (MK)
   2. How to use critical pathways and clinical practice guidelines to help guide therapeuticdecision making. (MK)
   3. Factors that frequently alter the effects of medications, including drug interactions andcompliance problems. (MK)
   4. Factors to consider in selecting a medication from within a class of medications. (MK)
   5. Factors to consider in monitoring a patient’s response to treatment, including potentialadverse effects. (MK)
   6. Methods of monitoring therapy and how to communicate them in both written and oral form.(MK)
2. Skills: Students should be able to demonstrate specific skills, including:
   1. Formulating an initial therapeutic plan. (PC)
   2. Accessing and utilizing, when appropriate, information resources to help develop anappropriate and timely therapeutic plan. (PC, PLI)
   3. Writing prescriptions and inpatient orders safely and accurately. (PC)
   4. Counseling patients about how to take their medications and what to expect when doing so,including beneficial outcomes and potential adverse effects. (PC, CS) 5. Monitoring response to therapy. (PC)
3. Attitudes and professional behaviors: Students should be able to:
   1. Incorporate the patient in therapeutic decision making, explaining the risks and benefits oftreatment. (CS, P)
   2. Respect patient’s informed choices, including the right to refuse treatment. (P)
   3. Recognize the importance of and demonstrate a commitment to the utilization of other healthcare professionals in therapeutic decision making. (P, SBP)