stanford rheumatology fellowship program...
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STANFORD RHEUMATOLOGY FELLOWSHIP PROGRAM
HANDBOOK 2018 - 2019
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Stanford has a track record of training many physician investigators and thought leaders in
Rheumatology. Highlights of our ACGME accredited Rheumatology Fellowship Program
training program include:
An entirely new Core Curriculum that includes competencies and evaluations
required by ACGME, and recommended by The American College of Rheumatology
(ACR)
Training at 3 large, outstanding hospitals in the San Francisco Bay Area
New clinical electives in disciplines such as pediatric rheumatology; radiology;
Derm/Rheum clinic; sports medicine; ophthalmology; renal; pulmonary; physical
medicine and rehabilitation, and private Rheumatology practice
Dedicated “Specialty Teaching Clinics” with clinical and research experts –
Rheum/Derm, Vasculitis
Opportunities for formal ultrasound training that enables fellows to later seek
certification
World-class research in health outcomes, clinical trials, basic immunology,
engineering, education, and translational medicine
Superb clinicians, a vibrant patient base, and excellent facilities
Stanford Adult Immunology and Rheumatology now ranks No. 12 in the nation by US
News Ranking
An active Chronic Immunologic Diseases Registry and Repository composed of over
1,600 subjects
A medical school (completed in 2010) and medical center (a $1B new hospital is
under construction) that are located on a spectacular, >8,000 acre, university
campus
WELCOME TO THE STANFORD ADULT RHEUMATOLOGY FELLOWSHIP PROGRAM
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Two different training tracks designed to provide personalized education for fellows
interested in “wet lab” research; “dry lab” research; translational research; or
education and patient care
Superb quality of life, with year-round sun, and easy access to Lake Tahoe, San
Francisco, Yosemite National Park, Napa Valley, the Monterey Peninsula, and the
Pacific Coast
The goal of our program is to train the next generation of leaders in the field of
Rheumatology. We are excited about the many changes in our program, nearly all of which
involved input from our fellows themselves.
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Table of Contents
WELCOME INFORMATION ABOUT THE RHEUMATOLOGY FELLOWSHIP PROGRAM ....................................... 2
TABLE OF CONTENTS ................................................................................................................................................ 4
RHEUMATOLOGY FELLOWSHIP ADMINISTRATIVE INFORMATION ..................................................................... 6
IMPORTANT FELLOWSHIP INFORMATION FOR NEW FELLOWS .......................................................................... 8
STANFORD ............................................................................................................................................................... 8
VA .............................................................................................................................................................................. 9
SANTA CLARA VALLEY ......................................................................................................................................... 10
STANFORD CLINIC AND SPECIALTY CLINICS .................................................................................................... 10
VA CLINIC ............................................................................................................................................................... 11
VALLEY CLINIC ...................................................................................................................................................... 12
STANFORD / VA CONSULT ................................................................................................................................... 13
VALLEY CONSULT ................................................................................................................................................. 14
EPIC INBOX ............................................................................................................................................................ 14
RHEUMATOLOGY CONFERENCES ...................................................................................................................... 15
PARKING ................................................................................................................................................................. 15
MISCELLANEOUS .................................................................................................................................................. 16
MAIL ........................................................................................................................................................................ 16
BUSINESS CARDS AND WHITE COATS ............................................................................................................... 16
STRUCTURE AND CLINICAL SITES ......................................................................................................................... 17
VACATION, EDUCATIONAL LEAVE AND SICK LEAVE POLICY ............................................................................ 18
ABSENCE FROM CLINICAL DUTIES ..................................................................................................................... 19
TRAVEL POLICY ..................................................................................................................................................... 20
CLINICAL DUTIES/ RESPONSIBILITIES ................................................................................................................... 21
CONSULT SERVICE RESPONSIBILITIES ................................................................................................................ 24
FACULTY SUPERVISION OF CARE POLICY ........................................................................................................... 25
TRANSFER OF CARE (HANDOFF) POLICY AND HANDOFF TEMPLATE .............................................................. 30
STANFORD RHEUMATOLOGY HANDOFF TEMPLATE ........................................................................................ 32
DUTY HOURS POLICY .............................................................................................................................................. 33
MOONLIGHTING POLICY .......................................................................................................................................... 38
FELLOWS CROSS COVERAGE POLICY .................................................................................................................. 39
PROFESSIONALISM AND COLLEGIAL BEHAVIOR ................................................................................................ 40
FEEDBACK AND EVALUATION OF FACULTY AND COLLEAGUE FELLOWS ...................................................... 41
CONFERENCE ATTENDANCE .................................................................................................................................. 42
REQUIRED EDUCATIONAL CONFERENCE SCHEDULE ..................................................................................... 42
IN-SERVICE EXAM ................................................................................................................................................. 43
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SCHOLARLY ACTIVITIES .......................................................................................................................................... 44
YEAR ONE .............................................................................................................................................................. 44
YEAR TWO .............................................................................................................................................................. 44
MENTORING PROGRAM ...................................................................................................................................... 46
REVIEW OF PERFORMANCE AND DEMONSTRATION OF COMPENTENCIES ..................................................... 46
EVALUATION OF THE FACULTY AND PROGRAM DIRECTOR ........................................................................... 51
HOW THE FACULTY, KEY CLINICAL FACULTY AND FACULTY FOCUS GROUP SUPPORT / CONTRIBUTE TO
THE FELLOWSHIP ............................................................................................................................................ 52
PROGRAM DIRECTOR RESPONSIBILITIES............................................................................................................. 53
DURATION OF FELLOWSHIP TRAINING ................................................................................................................. 55
RHEUMATOLOGY BLOCK DIAGRAM CLINICAL SERVICES SCHEDULE ............................................................ 56
FACULTY AND PROGRAM RESEARCH LINKS ....................................................................................................... 71
STANFORD DICTATION INSTRUCTIONS ................................................................................................................. 89
FELLOWS NOON CONFERENCE SCHEDULE ......................................................................................................... 92
APPENDICES:
1. Stanford Rheumatology Milestones Based Curriculum
2. Rotation Specific Goals and Objectives
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Program Director (PD) Neha Shah, MD Office: (650) 498-5630, Cell: (954) 324-5927, Pager #23491
Site Directors (SD) Mark Genovese, MD - Stanford Clinic Chief Lorinda Chung, MD - PAVAH Thomas Bush, MD - SCVMC
Key Clinical Faculty (KCF) Thomas Bush, MD, Lorinda Chung, MD, Mark Genovese, MD, Jison Hong, MD and Stanford Shoor, MD
Division Faculty
C. Garrison Fathman, MD Janice Lin, MD Stanford Shoor, MD Lorinda Chung, MD Rob Fairchild, MD, PhD Samuel Strober, MD Mark Genovese, MD Kate Lorig, Dr. P.H Paul J. Utz, MD Jorg Goronzy, MD, PhD Michael G. Lyon, MD Yashaar Chaichian, MD Julia Simard, PhD William Robinson, MD, PhD Cornelia Weyand, MD, PhD
Halsted Holman, MD Neha Shah, MD
Affiliated Clinical Faculty (ACF)
Vibeke Strand, MD Joseph Isaacson, MD Nancy P. Cummings-Beim, MD James Raitt, MD Thomas Bush, MD Amy Elliott, MD Alvina Chu, MD Jennifer Burkham, MD Lily Kao, MD Jeffrey Urman, MD Veronika Sharp, MD Cathy L. Riker, MD Amy Elliott, MD Umaima Marvi, MD Arthur Bobrove, MD Jane Nishio, MD
RHEUMATOLOGY FELLOWSHIP ADMINISTRATIVE INFORMATION
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Fellowship Coordinator Johanna Alm Office: CCSR, Room 4125 269 Campus Drive West Stanford, CA. 94305 Email: [email protected] Phone: (650) 497-3894
Administrative Support
Mario Martinezruiz, VAH ([email protected]) Lupe Ibanez, SCVMC ([email protected])
Current Fellows
Name Stanford Email Pager # Cell #
Audra Horomanski [email protected] 24393 (330) 564-7723
Kate Kolstad [email protected] 24296 (805) 698-6121
Anna Postolova [email protected] 14473 (310) 625-2041
Brian Abe [email protected] 14897 (718) 300-7575
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Stanford
Stanford Clinic Main line: (650) 723- 6961, Fax (650) 723-3059
Stanford Clinic Nurse Practitioner- Christy Bill (650) 736-6961
Scheduling New Stanford Patients: send email to:
[email protected], or send an EPIC staff message to
your medical assistant
Stanford ED (650) 723-7208
Stanford GME (650) 723-5948
Johanna Alm (650) 497-3894
SUH Dictation number: call 233 from within the hospital (outside # 1-800-242-9770), then
enter your 6-digit doctor number, then 68 for the location then 36 for letter type. Press 2 to
stop/start the dictation, 3 to reverse and 8 to end the dictation.
Stanford Page Operator 650-723-6661 (dial 288 inside the hospital)
Stanford Direct Paging Line: (650) 723-8222 (dial 222 inside the hospital), use this number
if you know the person’s pager ID OR to change your covering status (automated system to
have your pager covered by someone else or made unavailable—refer to the little paging
book you received with your pager for instructions); when in doubt, just call the page
operator directly.
Stanford Paging
Returning pages: most extensions are 721, 723, 736 or 498. From inside the hospital just
dial the 5 digit extension. From outside the hospital, dial (650) 72xxxxx, 73xxxxx or
49xxxxx). If it is a 6-xxxx, and it is not working, it is probably a VA number. If any issues,
just call the page operator. Paging someone else: easiest to text page using SmartPage
(www.smartpage.stanford.edu), use your SuNet ID to login remotely). Can call page
operator and ask them to page to your cell or callback #. Also can dial direct paging line and
IMPORTANT FELLOWSHIP INFORMATION FOR NEW FELLOWS
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enter a call back # (if you know their pager id). SmartPage can also be added to your EPIC
menubar.
Can arrange to have your pages forwarded to an iPhone, also can arrange for the page
operator to call you when you have a page (would only do this if you accidently forget your
pager or if it is a weekend, etc. and you don’t expect to get paged much).
VA
Mario Martinezruiz (650) 493-5000, ext. 64288
Rheumatology Care Coordinator: Irina Gorodetskaya (650) 493-5000 ext. 60188
Dr. Lorinda Chung: (650) 493-5000, ext. 62042
VA scheduling patients (new or follow-ups): email Waage, David [email protected],
as well as [email protected] and cc "Chung, Lorinda"
[email protected] OR call Mario Martinezruiz @ above #
VA Page Operator: (650) 493-5000 (dial 0 from inside the hospital); VA page operators are
generally unhelpful. Would suggest calling the Stanford page operator if you need to page
someone at the VA (most of the pagers are the same for Stanford/VA attendings/residents).
VA paging
Returning pages: start with a 6-xxxx; (although this can be 736 ext. at Stanford—ideally
they page you with the entire callback #). To return the page, call into the VA: (650) 493-
5000 press 1, 1, then the 5-digit extension.
Paging someone else: as above, use Smartpage or Stanford page operator. If you know
the person’s page ID number, you may call VA extension 65970 and dial in the page ID and
your call back number.
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Santa Clara Valley
Valley Clinic: (408) 885-5976
Valley Page Operator: (408) 885-5000.
Valley Paging Returning pages: All #’s (408) 885-xxxx or 793-xxxx. Paging someone else: SCV
residents/attendings have 7 digit pager #s, preceded by 408. Dial the 10 digit number
directly and enter your callback ID.
Can also textpage through archwireless.com if you know the pager ID. Look up pager IDs
for the resident covering your patient through www.amion.com (password is scvh), can also
text page directly by clicking on the pager ID link on amion.
Stanford Clinic and Specialty Clinics This is your own continuity clinic. Patients can be reviewed in advance by accessing Epic
remotely.
Rheumatology Clinic is located on the 2nd floor Blake Wilbur. Monday morning clinic starts
at 8:30am and Tuesday/Thursday afternoon clinic starts at 1pm.
For new patients, there will usually be a packet of info on the patient from the doctor the
patient was referred from available the day of clinic. Some patients may have outside
medical records that you can review in Care Everywhere.
New patients can be presented to any attending unless the consult asks for someone
specific.
Follow-up patients should be presented ideally to the attending that most often sees the
patient.
Notes are typed into Epic for follow-ups.
Notes are dictated as letters into Epic for new patients and sent to the referring physician.
The letter should state it is a “consult” not a “referral” (billing issue) and should start as a
letter to the referring doctor (Ex. “Dear, Dr, X- thank you for requesting this consult for
evaluation of xxxx”. OK to type letter in Epic, if you prefer.
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Results of labs and studies you order for patients will be sent to you- be sure to follow up
on them. You can ask your attendings or 2nd year fellows if you have any questions about
them.
The clinic number for patients to call is (650) 723-6961 and the fax is (650) 723-3059. DO
NOT give out your personal cell number. Patients can reach you through your patient care
coordinator. We also discourage giving out your personal email—use MyHealth instead. On
the weekends or after hours, if patients call the clinic line, they will be directed to the page
operator who can page the on-call fellow.
Rheum/Derm Clinic
This is a Stanford clinic located in the outpatient building in Redwood City, off Woodside Rd,
near 101.
Drs. Lorinda Chung (Rheum) and Dave Fiorentino (Derm) are the attendings
Clinic is every Monday from 1:00 pm – 5:00 pm
You are expected to split the patients up with the other fellows/residents in clinic, but do not
have responsibility for follow-up (Dr. Chung will do this). Every patient is seen by a Derm
resident AND a rheum fellow/resident.
VA Clinic
Wednesday morning starts at 9 am and is located in Building 5, 2nd Floor. You see new
patients as they come in, and then acquire them into your continuity clinic if they are going
to be seen in follow-up. Present to any attending.
Thursday morning is your own continuity clinic. It starts at 8:30 am and is located in the
main hospital in Clinic Area B on the 1st Floor. Ideally you should present to the same
attending who has seen the patient before.
Patients can be reviewed in advance by accessing CPRS remotely. – Email Mario to get
remote access set up (it can take several weeks).
You are in charge of follow-up of labs/studies—you can arrange your CPRS alerts so that
any abnormal tests come to your inbox.
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If patients have questions or need to call the clinic the number to call is. They can call (650)
493-5000 ext. 60188 and leave a message. The Rheumatology Care Coordinator, Irina
Gorodetskaya, checks the machine and will let you know if your patient has an issue.
You will need to contact Renee Kawahara to arrange for training on the VA Secure
Message System. VA patients often communicate with us via this system. See Dr. Lyon for
contact information on Ms. Kawahara.
For scheduling issues- email David Waage, and cc Lorinda Chung or Mario Martinezruiz.
Valley Clinic
This is located in the building adjacent to the hospital (Valley Subspecialty Clinics) on the
5th floor. Morning clinics start at 8:45 am (except Friday starts at 9:30 (10:00 on the first
Friday of the month)) and afternoon clinics start at 1:30pm.
The first day you get there, you will just be getting your badge, learning the EMR, and
getting an orientation from Dr. Bush- be sure to ask him for the syllabus- it has a lot of
useful information in it.
Patients you see are the attending’s patients so there is not continuity; however, this is
where you get a lot of your injection experience.
There are 4 attending docs – Jen Burkham, Veronika Sharp, Umaima Marvi and Tom Bush.
It will vary when they have clinics. You will be oriented how the clinic works during your first
week.
You are not in charge of follow-up of labs/studies of these patients.
If you are attending a morning clinic prior to a noon conference, plan to leave no later than
11:15 to make it back to Stanford in time. All the Attendings know this and expect it. You
should not miss/be late for conference.
Two Wednesdays out of the year you will be asked to give a Rheum talk to the Valley
residents. They will email you way in advance on this.
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Stanford/VA Consult
When on Stanford/VA consult you cover consults for both hospitals. Your pager should be
on 24/7 except for the 4 days you have off during that month. You can have your pages
sent to your cell phone as texts- we can tell you how to do that.
The Valley Fellow will cover your service (and theirs) on the 2nd and 4th weekend of the
month. (The weekend starts at 5pm on Friday and ends 8am Monday) If you need to switch
weekends- you need to ask Tom Bush far in advance so that the Valley schedule can be
switched.
Angie Aberia will email you a few days before asking for “the consult schedule”. All she
needs to know from you is when the Valley fellow will be covering you. She will give the
times to the page operator.
Rounding time is attending & fellow dependent. All will work with you to meet at a time
you are not in clinic.
In Patients: You should be familiar with all the patients on service, even if a resident is
following them. Add all patients to EPIC under- Patient list- Shared patients-
Rheumatology (we can show you how to do this)
Grand Rounds: You are in charge of putting together a power point case presentation for
Grand Rounds each week during your consult month. Generally, interesting cases, cases
with a diagnostic or treatment dilemma etc. are good choices. Sometimes handing out some
literature or putting up a couple slides reviewing some literature relevant to the case is
useful but not always. Write down the names of any interesting cases that you don’t get to
present in case you need a case in the future. If you have no inpatients to present you can
present a clinic patient with diagnostic or treatment dilemma or ask around to see if
someone else has a case they could present (just don’t wait until the day before to ask-they
can take a while to prepare)
If you receive a page from “the ATIC” this is the infusion center at Stanford. Things they
page you for are potential drug reactions, abnormal vital signs, and incomplete/incorrect
orders. If you have any questions- ask someone (the attending on with you or one of us).
Also- FYI- Infusions are done 7 days a week. A separate AITC policy was instituted in 2013
and can be found later in this handbook.
If you receive a call for Allergy (i.e. how to desensitize someone from aspirin or a question
about a hypersensitivity reaction, etc.), direct them (and preferably the page operator) to the
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peds allergy fellow on-call—they take all allergy calls, since we do not have an adult allergy
fellowship program.
If you receive a consult from a PAMF primary care or rheumatology patient, or a Menlo
Clinic rheumatology patient, please direct the requesting team to contact the appropriate
PAMF or Menlo Clinic rheumatology attending on call.
Valley Consult
You typically share consult call with the resident on service. You will be given a separate
Valley pager (calls will not come to your Stanford pager).
You have 3 (rather than 1) clinics at the Valley when on consult month. These are always
Mon, Wed, and Friday afternoons.
When you get a new consult you should immediately call the attending on-call with you to
tell him/her about it. If it is a day you happen to be at the Valley, you may be asked to see
the consult. If it is not a day you are going to be at the Valley, the attending and resident
see the consult on their own.
The valley consult schedule is available on www.amion.com password scvh.
EPIC Inbox
The inbox contains urgent patient calls who have new symptoms or need to talk to their
doctor, staff communication and med refills. The burden is significantly less now, as all
symptom calls are triaged first through an RN or NP before being forwarded to you.
Every Fellow should be logging into Epic at least 2-3x/week). As the box continues to fill
during the day- deal with urgent issues 1st, which should be flagged in red (usually patient
calls).
Fellows should not cover Faculty patients in the inbox. As a courtesy, let the faculty know by
email and in EPIC. For urgent or emergent issues, contact the Faculty member by phone or
page, and if the Faculty is not responding discuss with the On Call Consult Attending. If the
On Call Attending is not responding, this is inappropriate behavior and must be reported
immediately to the PD who will assist with the emergency.
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Rheumatology Conferences
Fellows Friday Conference – 10:45 am -11:45pm, given by faculty members. 1000 Welch
Road, Suite 315. Conference coordinator: Johanna Alm, (650) 497-3894.
Monthly Radiology Conference – given by Michelle Nguyen or Kate Stevens once a
month on Tuesdays. Kate Stevens, 12:00 pm – 12:45 pm at Stanford Hospital, MSK
Reading Room. Michelle Nguyen, 11:00 am – 12:00 pm at VA DRC Conference Room,
Building 102.
Thursday Grand Rounds – 5:00 pm - 6:00pm, Blake Wilbur 1st Floor conference room.
Case presentations given by fellow on Stanford/VA consult. Conference coordinator: Angie
Aberia, (650) 498-5630.
Friday AM pre-Clinic Conference and Board Review — 8:30 am – 9:00 am, Blake Wilbur
Immunology-Rheumatology Clinic. Dr Shoor will inform fellows or dates for Board Review.
Friday Journal Club – 12:00 pm -1:00pm, Blake Wilbur 1st Floor conference room (in
CCSR once/month when there is a division meeting following the conference). Lunch is
provided. Coordinators: Angie Aberia, (650) 498-5630 and Linda Arneson (650) 723-9027.
Parking
Stanford: you can get a permit for lots A or C. There is no longer a huge difference in price
between A and C parking. Walking from either parking lot takes about 10 minutes. Budget
for additional walking time in your schedule. If you buy the annual 12-month permit, you can
get automatic payroll deduction (tax-free). Parking passes can be picked up at the
transportation/parking office, or you can purchase online (takes about a week to mail).
VA: Parking at the VA is free. There are two large parking structures. Structure # 2 is
closest to the Wednesday Clinic in Building 5. To access Structure 2, turn right AFTER you
turn into the main entry driveway. Structure #1 is closest to the Thursday Clinic in Building
100. To access Structure 1, turn LEFT after you turn into the main entry driveway. Do
NOT drive more than 15 mph in the parking lot or the cops will ticket you for speeding.
They will also nab you for talking on your phone.
Valley: free, in the C lot, you will get a permit on your first day (ok to park in visitor parking
on your first day). Parking structure is a 5 min walk from the clinic.
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Miscellaneous
Requesting time-off for vacation– make sure all of your clinics are cancelled in advance
(needs to be at least one month in advance). Notify the Program Coordinator of your
vacation days so she can enter into MedHub. Except in cases of health or family
illness/emergency the one month advance notice for clinic cancellations is STRICTLY
ENFORCED.
In general, you can take vacation any time you are not on Stanford/VA Consult, but
preferably during your non-consult responsibilities months. Fellows are allotted a total of 3
weeks of vacation per academic year which do not need to be taken consecutively.
However, time off needs to be taken in at least 1 week blocks.
VA - Contact David Waage and send an email to
[email protected] and cc Dr. Chung to cancel VA clinics (for
Thursdays). If you are going to miss a Wed clinic, let Dr. Chung know as well, since he may schedule fewer new patients
Stanford –Email and get approval from Dr. Genovese
Valley – Email and get approval from Dr. Bush
MAKE SURE TO WORK WITH SPECIALTY CLINIC ATTENDINGS
(Rheumatology/Dermatology, Vasculitis) TO INSURE THAT FACULTY SCHEDULES ARE
ALSO ALTERED FOR YOUR VACATIONS! This is the responsibility of the Fellow to notify
the clinical scheduler and the Specialty Clinic attending. CC the PD on all time off emails, so
s/he is aware as well
You have a mailbox at 1000 Welch, Suite 203
Business Cards; White Coats; Pagers (Spok Mobile)
Johanna Alm will have business cards made and a white coat with your name.
GME also gives you a white coat which can be swapped out with a clean one at any time,
Stanford Hospital Linen Services, Basement Hospital.
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Structure
Two year Clinical Fellowship with Board Eligibility
Eligible for additional 1-2 year NIH Research Training Grant for Investigators in
Clinical or Basic Science in Rheumatic Diseases
Clinical Sites
Santa Clara Valley Medical Center (SCVMC)
Palo Alto Veterans Hospital and Medical Center (PAVAH)
Stanford University Hospital and Clinics (SUH)
Lucille Packard Children’s Hospital (LPCH)
STRUCTURE AND CLINICAL SITES
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Vacation, Sick, Maternity and Paternity leave for Year 1 and 2 Fellows are governed by the
Stanford GME policy handbook, page 47. http://med.stanford.edu/gme.html
Fellows do not accrue vacation. Fellows are permitted to take up to three (3) weeks of
personal time off with pay during each one-year period (July 1 through June 30). Personal
time off needs to be agreed upon at least 30 days in advance. Fellows are not allowed to
take personal time off during Stanford Consult time and time off needs to be taken in at
least 1 week blocks.
Fellows will be granted up to 20 days of sick leave (4 weeks) per year, if needed. Fellows
do not accumulate sick leave credit, and no additional compensation will be paid for unused
sick leave.
Each Fellow has 5 days of Educational Leave per year to attend Director-approved
educational and/or scientific meetings. In addition to these 5 days, Senior Fellows are
allotted 2 days to attend the UCSF Boards Review Course, and expenses are covered by
the fellowship program.
All vacation days and educational leave must be approved in advance by the PD and
Director of Clinical Service at the VA, SCVMC and Stanford.
1. Fellows will first submit a request to Drs. Genovese, Chung and Bush
2. If approved the request will be reviewed by the Program Director
3. If s/he approves the request, it will be forwarded to Johanna Alm who will check
whether the Fellow has vacation or Education leave remaining. If they do, she
will send out a confirmation to the PD and all three clinic chiefs.
4. Confirm with program coordinator your leave as she needs to enter your specific
leave times in MedHub.
The Fellow is responsible for any scheduled patient visits or anticipated patient visits.
First year Fellows are expected to cover a 12-hour shift for the Internal Medicine Residents
during their annual retreat in April. Vacation cannot be taken at this time. The Medicine
Residency Department will announce the date in sufficient time for the 1st Year Fellows to
plan vacation or leave.
VACATION, EDUCATIONAL LEAVE AND SICK LEAVE POLICY
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Planned Absence from Clinical duties for other than sick leave or approved vacation may
include: time for job interviews, attendance and/or presentation at educational conferences.
All such absences must be approved in advance by the PD and if they exceed allotted
vacation time and clinic holidays, they must be taken without pay.
If a research meeting interferes with clinical duties, the Fellow will be excused from clinic
only if:
a. The research meeting involves the Fellow’s own original research project.
b. The Fellow has made every effort possible to re-schedule the meeting and there
are no alternatives.
c. The Fellow receives approval from the PD and informs the relevant clinic at least
four weeks in advance so that patients can be re-scheduled.
d. Requests that do not meet these guidelines are unlikely to be approved but may
be discussed with the PD if extenuating circumstances exist.
Any absence from clinical responsibilities must not interfere with the quality or safety of
patient care of patients in the Rheumatology clinics or hospitals. Failure to adhere to this
standard will result in probation.
Unapproved absence from clinical responsibilities will result in probation.
ABSENCE FROM CLINICAL DUTIES
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All fellows are eligible for funding for travel as follows:
UCSF Rheumatology Boards Review Course
Senior Fellows are required to attend this course each fall, which does not count toward the
5 days of educational leave allotted to individual fellows each year. The Fellowship Program
will pay for registration and parking fees. Because the course is in SF (less than 60 miles
from campus), Stanford University rules do not permit payment for meals. Coverage for the
consult service will be provided by Junior Fellows on service and the Rheumatology
Attending who is on service during the course.
ACR Meeting
Both senior fellows and one first year fellow may attend the ACR meeting, which this year is
in Chicago. Fellows are required to apply for ACR-FIT travel awards and should share
housing with another fellow unless this is not feasible. For the 2018 meeting, a maximum of
an additional $1,000 will be provided by the Division to support travel (RT coach fare
purchased >30 days before travel, local transportation, meals without alcohol, registration,
and hotel). Costs exceeding $1,000 plus ACR travel awards are to be paid by the fellow,
who can petition the PD for additional funding.
Other Meetings
The one fellow who does not attend ACR meeting in order to cover the inpatient consult
service will be allowed 1 of 2 options: Attend the UCSF Board review course OR attend
another national or international Rheumatology conference of his/her choice with up
to $1500 travel reimbursement available from the Division. Fellows attending MUST be
presenting an abstract, poster, oral presentation at the meeting he/she attends, except in
the case of the UCSF Board Review Course.
TRAVEL POLICY
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Clinics
Fellows are required to do 1-8 clinics per week depending on their Year, the clinical
pathway which they have chosen and documented level of ACGME Competency. (see
Appendix I-B “Clinics”).
At the conclusion of Year 1, Fellows will choose whether they will enter one of two
pathways: Clinician Investigator or Clinician Educator. The former emphasizes acquisition
of skills for an investigative career and anticipates that the Fellow will continue their training
in a 3rd and probably 4th year in the NIH T32 Training Program. The latter, emphasizes
skills for clinical practice and teaching and anticipates the Fellow will complete their training
by Year 2 and enter a career in clinical care and teaching.
Fellows are expected to be present from the start of a scheduled clinic until the scheduled
end of the clinic.
Fellows are expected be groomed and dressed in a professional manner, following existing
clinic and hospital policies.
Fellows should review their schedule at the beginning of year and if they feel there should
be changes, they must be discussed with the PD. Fellow schedules may be changed by the
PD to facilitate clinical skills development or to accommodate research training activities for
Fellows in good standing.
Fellows are responsible for all patients on their continuity clinic schedule including new
consultations, regular clinic patients who are new to them, and their patients scheduled for
return visits.1
1This applies to patients who cancel or “do not show” for an appointment OR to patients
who the Fellow or an Attending thinks should be seen earlier than regularly scheduled. If a
patient “does not show” the Fellow and Attending are jointly responsible for determining
whether the patient needs to be re-scheduled and in what time frame.
-In the event of an emergency or when a patient must be seen urgently and a Fellow is
unable to see the scheduled patient in an appropriate time frame, they are responsible for
finding one of their colleagues who can see the patient (in the following order)
-On call Fellow
-Fellows not on call
-On call Consult Attending
CLINICAL DUTIES / RESPONSIBILITIES
22
-Program Director
-Another Faculty member
If the Fellow is unable to find an alternative as outlined above they are required to care for
the patient–either by email, telephone contact or office visit.
Once a patient is assigned to a Fellow, it is the Fellow’s responsibility under all
circumstances to care for that patient. If another Fellow or a Faculty member sees the
patient, the Fellow to whom the patient was originally assigned is responsible for resuming
their care thereafter.
Residents and medical students will be assigned patients scheduled for Faculty rather than
Fellows. However, if a Fellow wishes a resident or medical student to see a new consult on
the Fellow’s schedule, it is the Fellow’s responsibility to assume patient care responsibilities
for the patient thereafter.
The above applies to patients who cancel or “do not show” for an appointment OR to
patients who an attending physician requests be seen earlier than regularly scheduled.
If a patient checks in at the reception desk more than 30 minutes after their scheduled
appointment time but before 5pm, the Fellow must care for the patient in a manner that is
medically appropriate and meets the patient’s needs. They must communicate with the
patient and offer them one of several alternatives:
1. Offer to see the patient at the end of the clinical schedule, if possible.
2. If the patient does not wish this option then the Fellow must either re-schedule
the patient in an appropriate time frame or contact the patient by telephone or
email for care.
a. The Fellow is responsible for determining what is an “appropriate time
frame” by considering safety, quality of care and patient satisfaction.
b. The Fellow must discuss her/his assessment and decision with an
attending at the end of clinic or on clinic days when Grand Rounds is held.
c. For example, if no Faculty are able to staff a non-urgent late patient with a
Fellow, then the Faculty may determine when the patient should be
rescheduled.
d. Patients who are repeat no-shows or late offenders should be discussed
with Faculty and the Clinic Director to determine whether continued care
is appropriate. Decisions regarding termination of care must be made
with the guidance of a Faculty member.
Fellows will typically have their Continuity Clinic at Stanford on Tuesday afternoons.
Exceptions will be considered on an individual basis.
23
Specialty Clinics
Rheum Derm /Scleroderma/Myositis – Drs. Chung and Fiorentino. Takes place Mon pm
at the Redwood City campus. Fellows will see patients on Dr. Chung’s schedule. There will
be a pre-clinic conference in which Fellows will be assigned cases and they will be
discussed.
Vasculitis, and SLE --These clinics will take place on Thurs PMs at Stanford Hospital
Clinic, except as otherwise pre-arranged with the attending. A Fellow will be “assigned” to a
schedule with one of the Faculty who will see the patients on that Faculty member’s
schedule. Fellows should discuss which patients they are assigned with individual Faculty,
as their clinic schedules and teaching styles may differ.
-Vasculitis - Dr. Weyand
- SLE and CTD – Dr. Chaichian
Fellows are expected to review their own EPIC “inbox” daily and to respond to nonurgent
messages, refill and lab requests, questions and problems within 72 hour during the
working week. Seventy two hours is the maximum time period, but it should be noted that
effective patient care and patient satisfaction are better served with more rapid completion
of EPIC requests. Should a Fellow be unable to do so for any reason, it is her/his
responsibility to arrange to have one of her/his Fellow colleagues to do so for them.
Fellows are expected to make every effort to work with their colleagues in a fashion that
fosters cooperation, encourages support, and above all keeps patient safety and care as a
first principle.
Faculty are responsible for reviewing the “inbox” on their own patients at least every 72
hours. Clinic staff will be instructed to send all “inbox” items on Faculty patients to the
appropriate Faculty’s “inbox”. If a Fellow finds in reviewing his/her own “inbox” that they
have an item regarding a Faculty patient, they will forward the item to the appropriate
Faculty member. If the appropriate Faculty member is unable to respond in a timely fashion
the Faculty member is responsible for assigning his/her inbox to a Faculty colleague. In
emergencies or in the event that the Faculty member or his/her assigned colleague is not
responding in a timely manner, the on call Faculty member should be paged and take care
of the patient. All such events must be reported to the PD, preferably by cc’ing the PD on
the EPIC encounter. The PD will then discuss the problem with the responsible Faculty
member(s).
24
Please review the following documents which relate to clinic services:
- Faculty Supervision Policy
- Transfer of Care (Handoff) Policy
- Duty Hours
- Moonlighting Policy
- Fellows Cross Coverage Policy
Fellows are assigned to the Stanford/VAH or SCVMC Consult service according to the
Schedule in Appendix I. They are required to be available by pager after hours and
weekends during the assigned month and are expected to round on patients daily. They
are expected to pre- round on patients prior to Faculty attending rounds and need to be
available to round after clinic if necessary. Consults that are called during a scheduled
clinic must be seen after clinic. If a consult is deferred until the following day, this must be
approved by the Consult Attending. Just as in the Clinics, Fellows need to see all patients
even if they assign a resident to see them first. Please review the following documents
which relate to consult services:
- Faculty Supervision Policy
- Transfer of Care (Handoff) Policy
- Duty Hours
- Moonlighting Policy
- Fellows Cross Coverage Policy
CONSULT SERVICE RESPONSIBILITIES
25
Overall fellow trainee supervision is the responsibility of the Rheumatology Program
Director. Supervision of clinical activities is the responsibility of rheumatology clinic and
consult attending physicians at each site (Stanford, PAVAMC, PAMF, SOAR, SCVMC, and
Lucille Packard Children’s Hospital).
1. Definitions
a. Direct Supervision
The supervising physician is physically present with the trainee and patient.
b. Indirect Supervision
• With direct supervision immediately available – the supervising physician is
physically within the hospital or other site of patient care, and is immediately available to
provide direct supervision.
• With direct supervision available – the supervising physician is not physically present
within the hospital or other site of patient care, but is immediately available by means of
telephonic and/or electronic modalities, and is available to provide direct supervision.
c. Oversight
The supervising physician is available to provide review of procedures/encounters with
feedback provided after care is delivered.
FACULTY SUPERVISION OF CARE POLICY
26
2. Supervision of Fellows
a. All patient care must be supervised by qualified faculty. Faculty schedules will be
structured to provide residents and fellows with continuous supervision and consultation.
b. Supervising faculty will be physically present in all outpatient rheumatology clinics at a
ratio not to exceed one faculty per 3 fellows and residents for direct and indirect
supervision, and for oversight of procedures.
c. A supervising attending physician will be assigned each month at each site
(Stanford/PAVAMC or SCVMC) as the consult attending. This faculty member will be
available to staff new inpatient rheumatology consults within 24 hours of the consultation
(direct supervision) and available for indirect consultation and oversight of the fellow 24
hours a day.
Example of a patient experiences that require direct supervision include the following:
• Outpatient clinics in which fellows are scheduled to see patients together with an
attending physician
Examples of patient experiences that require indirect supervision with indirect supervision
immediately available include the following:
• Outpatient clinic visits in which fellows care for unscheduled patients who will be
seen later during the visit, together with an attending physician
• Complex procedures such as arthrocentesis or joint injection of uncommon joints
• Prescription of biologic agents, infusible drugs, and chemotherapy. All chemotherapy
infusions must be cosigned by the attending physician prior to infusion
• Inpatient consults
• Emergency room encounters
• Ultrasound of joints
Examples of patient experiences that require oversight include the following:
• Review of laboratory data, radiographs, or other patient data
• Patient phone calls or electronic encounters
27
• Identification of crystals in joint fluid
• Routine joint injections or aspirations (e.g., the knee).
Additional Faculty Supervision, Education and Mentoring Policies include the following:
• Faculty will provide the house staff with syllabus, policies and procedures.
• Faculty will insure that all house staff complete the core curriculum and learn the
‘basics’ that are set out in the materials they receive – e.g., approach to a patient
with arthritis, joint exam, injection techniques, crystal exam, and other basic
rheumatology topics.
• Faculty will round every workday with team.
• Faculty will round on weekends with the fellow or resident on call.
• If a fellow asks to see a patient with them, under no circumstances can this request
be denied. Moreover, the attending will never tell a fellow that they should not have
been called.
• Faculty will plan "rough" rounding times (i.e. am vs. pm) with the fellow in advance
(ideally for the whole 2 week block, if possible), to accommodate both the fellow's
clinic schedule and attending commitments, as much as possible.
• Faculty will moderate or deliver 1 presentation on a selected rheumatology topic per
day.
• Faculty will moderate and lead Thursday evening Grand Rounds, including actively
involving all 4 fellows in the discussion. The attending’s role should be focused more
on the “big picture” rather than on the fine details of presenting the case.
• Faculty will go over the presentation by the fellow or resident prior to GR.
• Faculty must be at grand rounds on time, unless extenuating circumstances such as
provision of emergency patient care, exist. When on service, they should consider
blocking their 4:30 slot if necessary.
• Faculty or community physicians who have cases to present may contact the fellow
or attending and should be able to use some or all of grand rounds for interesting
patients or patients who they want help in managing. This may substitute for a fellow
or faculty presentation.
• Faculty must be available by cell phone or pager 24/7 while on service.
• Faculty must see all new consults in a timely manner. This includes PAVAMC (days,
nights, and weekends).
28
• Faculty must be available if needed to assist fellows with procedures.
• As described elsewhere in the Procedure and Policies Manual, it is the responsibility
of the attending who is starting on service to get patient sign-outs in writing, AND
either by phone or face-to-face, from the previous attending. The full policy can be
found in the “Transitions in Care” portion of the handbook. Although the fellow
provides continuity, in some cases the transition occurs when the fellows switch over
a "covering weekend" and it is required that both attending and fellow receive sign
out. The current requirement for fellow and faculty to cc the PD on all TOC emails
will remain in effect.
• Faculty must assist, where possible, with first call for urgent walk-ins or for cross-
coverage of faculty patients when those faculty are not in clinic or are traveling.
Evaluation
• MedHub evaluations must be filled out promptly by faculty, ideally at the time of
completion of the consult block (last day).
• The evaluations must be candid, constructive, and accurate.
• All faculty must meet with fellows and house staff face to face at the conclusion of
the rotation to discuss their performance and areas of improvement that are needed.
This FTF meeting must then be documented in MedHub.
• Problems must be reported immediately to the Program Director, preferably
including in an email marked “Privileged and Confidential – Fellow XXX.”
Suggestions for how the fellow can improve or areas of weakness must be passed
on directly to the Program Director and the next consult attending.
• The attending on service (especially if it is a 2 week or month block) will give
feedback early, e.g. mid-rotation, so the fellow has an opportunity to improve while
still under observation of the current attending.
• Faculty who are not meeting ACGME standards for mentoring and teaching will be
given concrete ways they must improve by the Program Director. Faculty who fail to
remediate may no longer be allowed to serve on the consult service, after
discussions with the Division Chief.
29
3. Supervision of Care, Cross Cover Policy
It is important that we recognize that the Consult attending on call needs to be available for
calls, 24/7 when on the consult service. Because of the multiple locations involved in the
care of patients in the program, it may be possible that the consult attending is off-site or in
a clinic at the time a consult is call. In virtually all the situations the consult will be seen by
the fellows and the consult team and can initially be discussed on the phone with the
consult attending until which time the consult attending can reach the location and staff the
consult in person. There may be times when the consult attending cannot reach the
location in the expected time frame to staff an emergency consult. In those situations the
consult attending should personally call or if necessary the consult fellow should:
1) Call the Clinic Chief of the respective institution, SUH or PAVAMC.
2) If the clinic chief is unavailable the call should go to a clinician actively working in the
clinic at the respective institution, SUH or PAVAMC.
3) In the unlikely event that the Clinic Chief, or practicing clinicians are all unavailable,
the call should then go to the Division Chief.
4) Finally, if the Division Chief is also unavailable the call should go the Fellowship
Program Director and/or Associate Director.
4. Supervision of Care, Infusion Center Policy
Infusion Center orders and calls:
1) Attendings write their own orders and renewals. Attendings must list their name, cell
phone and/or pager noting them as first call on the orders.
2) First call from Infusion Center = physician who wrote the orders
3) Second call = fellow on call; the consult attending should discuss infusion
management with the fellow at any time should the fellow request input/direction
4) Third call = Clinic Chief
5) Fourth call = any physician who is in clinic
30
Additional specific policies relating to fellow supervision at training sites are specified in the
Supervision Policy established by the Office of Graduate Medical Education.
Portions of this document were provided by the UCSF Adult Rheumatology Program, with
permission from Dr. David Daikh.
Best medical practice and the multiple opportunities for fragmentation of care in modern
healthcare systems require that systems for efficient and accurate transitions of care be in
place to ensure quality care and patient safety. Care transitions in rheumatology regularly
occur in the following settings:
1. On Monday morning at the end of a weekend call
2. At the end of the calendar month, at the end of an inpatient consult rotation
3. At the end of a trainee or attending vacation or other absence.
Formal handoffs of individual patients will occur at each of these transitions, as well as at
any other juncture at which a fellow and/or an attending transfer care responsibility to
another person. These will occur in-person whenever possible, and must include a written
summary of illness severity; active issues; current management and treatment plan; and
active contingencies (see below).
Handoffs must include at least:
• Patient summary (exam findings, laboratory data, any clinical changes);
• Assessment of illness severity;
• Active issues (including pending studies);
• The current management and treatment plan and active contingencies (“If/then”
statements);
• Synthesis of information (e.g. “read-back” by receiver to verify);
• Family contacts;
TRANSFER OF CARE (HANDOFF) POLICY AND HANDOFF TEMPLATE
31
• Contact information for other responsible healthcare providers;
• Any changes in responsible attending physician; and
• An opportunity to ask questions and review historical information.
Supervision of fellow contacts in general will be indirect. However, any discussion of
critically ill or unstable patients must include direct involvement and supervision by the
transitioning attendings as well.
Documentation of the Transition of Care Policy
1. Fellows will demonstrate competency in performance of this task. There are
numerous mechanisms through which a program might elect to determine the
competency of trainees in handoff skills and communication. These will include
each of the following:
Direct observation of a handoff session by a licensed independent practitioner
(LIP)-level clinician familiar with the patient(s)
Evaluation of written handoff materials by an LIP-level clinician familiar with the
patient(s)
Evaluation of written handoff materials by an LIP-level clinician unfamiliar with
the patient(s)
Didactic sessions on communication skills including in-person lectures, web-
based training, review of curricular materials and/or knowledge assessment
2. The Rheumatology Program will utilize the following monitoring checklist for the
transition of care process and update. Monitoring of handoffs by the program will
ensure that the following checklist is followed:
There is a standardized process in place that is routinely followed, based on the
items outlined above
There are consistent opportunities for questions. This will be facilitated by face to
face handoffs wherever possible
The necessary materials are available to support the handoff (including, for
instance, written sign-out materials, access to electronic clinical information)
A quiet setting free of interruptions is consistently available, for handoff
processes that include face-to-face communication. This is easily facilitated using
our rheumatology workrooms
Patient confidentiality and privacy are ensured in accordance with HIPAA
guidelines
32
Stanford Rheumatology Handoff Template
Date of Transition Transferring Attending Accepting Attending Transferring Fellow Accepting Fellow Patient
MRN
Service
Primary Attending
Contact phone number or pager
Family contact
Location at time of transfer
Illness severity
Relevant exam, labs, clinical changes:
Active issues/problem list:
Current management and treatment plan:
Active contingencies (if X, then Y):
Did verbal or FTF transition occur by Faculty? Y N
Did verbal or FTF transition occur by Fellow? Y N
Transitions in Patient Care – Handover Evaluation can be found in MedHub.
33
I. Purpose
To optimize the training environment for patient care, fellow learning, and fellow well-
being. To accomplish this, the program director will ensure that stress and fatigue among
fellows are minimized and that continuity of and quality/safety of patient care and fellow
education are optimized. Compliance with fellow duty hour requirements is an essential
part of meeting these goals but is not the complete answer. The program director and
supervising staff will ensure that fellow education and patient and fellow safety are
assured at all times above and beyond focusing on the number of hours worked.
II. Duty Hours Policy
A. Definitions
Duty hours are defined as all clinical and academic activities related to the fellowship
program. This includes inpatient and outpatient clinical care, in-house call, short call, night
float and day float, transfer of patient care, and administrative activities related to patient
care such as completing medical records, ordering and reviewing lab tests, and signing
verbal orders.
Hours spent on activities that are required by the accreditation standards, such as
membership on a hospital committee, or that are accepted practice in fellowship
programs, such as fellows’ participation in interviewing fellow candidates, must be
included in the count of duty hours. It is not acceptable to expect fellows to participate in
these activities on their own hours; nor should fellows be prohibited from taking part in
them.
Duty hours do not include reading, studying, and academic preparation time, such as time
spent away from the patient care unit preparing for presentations or journal club.
Duty Hours are to be recorded in MedHub each week by the Fellow.
B. General Requirements
The Rheumatology Fellowship Program strictly adheres to all Stanford Hospital & Clinics
House Staff Policies and Procedures, ACGME common program requirements, and RRC
requirements concerning duty hours.
DUTY HOURS POLICY
34
Institutional policies and procedures are provided to fellows with their contract and are
available on the GME website: http://med.stanford.edu/gme/policy/
The ACGME common program requirements can be found on the following website:
http://www.acgme.org/acWebsite/dutyHours/dh_dutyhoursCommonPR07012007.pdf
The RRC requirements can be found on the following website:
http://www.acgme.org/acWebsite/dutyHours/Specialty-specific_DH_Definitions.pdf
C. Specific Duty Hour Limitations
1. Duty Hours, further definitions
a. Duty hours are defined as all clinical and academic activities related to the
fellowship program, i.e., patient care (both inpatient and outpatient), administrative
duties related to patient care, the provision for transfer of patient care, time spent
in-house during call activities, at-home time involved directly in patient care while
on call, and scheduled academic activities such as conferences. Duty hours do not
include reading and preparation time spent away from the duty site. These
standards apply to all Stanford training sites including, but not limited to, the
PAVAMC, PAMF, SCVMC, SOAR, and Lucille Packard hospitals.
b. Duty hours will be limited to 80 hours per week, averaged over a four-week period,
inclusive of all activities, including moonlighting.
c. Fellows will be provided with 1 day in 7 free from all educational and clinical
responsibilities, averaged over a four week period, inclusive of call. One day is
defined as one continuous 24-hour period free from all clinical, educational, and
administrative
activities.
d. A minimum of 10 hour time period for rest and personal activities will be provided
between all daily duty periods.
2. On-Call Activities
The objective of on-call activities is to provide fellows with continuity of patient care
experiences throughout a 24 hour period. In-house call is defined as those duty hours
beyond the normal workday when fellows are required to be immediately available in the
assigned institution.
35
a. Fellows will not take in-house call.
b. At-home call (pager call) is defined as call taken from outside the assigned
institution.
c. The frequency of at-home call is not subject to the every third night limitation.
However, at-home call will not be so frequent as to preclude rest and reasonable
personal time for each fellow. Fellows taking at-home call will be provided with 1
day in 7 completely free from all educational and clinical responsibilities, averaged
over a 4-week period.
d. When fellows are called into the hospital from home, the hours fellows spend in-
house are counted toward the 80-hour limit.
e. The program director and the faculty will monitor the demands of at-home call in
their programs and make scheduling adjustments as necessary to mitigate
excessive service demands and/or fatigue.
3. Moonlighting – see separate moonlighting policy, summarized below.
a. The Program complies with the sponsoring institutions written policies and
procedures regarding moonlighting, in compliance with the Institutional
Requirements
b. Moonlighting that occurs within the fellowship program and/or the sponsoring
institution or the non-hospital sponsor’s primary clinical site(s), i.e., internal
moonlighting, will be counted toward the 80-hour weekly limit on duty hours.
4. Methodology for data verification The Fellow is expected to be at the hospital by 8 AM daily Monday-Friday except for those
days when clinics or conferences which they are expected to attend begin at specified
times, e.g. 8:30 or 7:30 AM. The workday ends between 5:00 PM and 6:00 PM Monday-
Friday. Therefore the work consists of a maximum of ~50 hours per week. Assignments
are reviewed by the Program Director monthly. Colleagues, staff and other house officers
are expected to evaluate the fellows on attendance, punctuality and adherence to the duty
hours on an ongoing basis. Fellows are queried about their workdays on a quarterly to bi-
annual basis during a meeting with the Program Director.
36
5. Stress and Fatigue
a. Education:
Fellows have access to many resources offered by the Stanford GME office
including the following support modules:
http://med.stanford.edu/gme/duke_life.html
b. Monitoring Methodology:
The Program Director and/or the Associate Program Director meet with fellows
quarterly in the first year, and semi-annually in the second year. The PD and APD
and review all MedHub records on at least a monthly basis. These procedures
provide the opportunity to review the fellow’s activities including work level and
fatigue. If the workload is unusually demanding, adjustments are made in the
schedule to reduce fatigue.
c. Backup systems for Fatigue:
If a fellow is found to be fatigued, the attendings provide supportive coverage to
cover the clinical responsibility.
D. Protocol for Remaining Beyond Scheduled Duty Period It is recognized that in unusual circumstances, fellows may on their own initiative, choose
to remain beyond schedule duty periods to provide care to a single patient.
These should only occur if:
a. continuity of care is required for a severely ill or unstable patient;
b. there is extreme academic importance to continuing involvement; or
c. humanistic attention to the needs of a patient or family can only be achieved
through continuing on duty
The fellow must document the reasons for remaining to care for the patient in question
and submit that documentation through MedHub in EVERY circumstance using the “drop
37
down” menu under “detailed description” which allows the fellow to select the pertinent
reason:
Emergency Patient Care
Patient/Family Needs
Continuity of an Unstable Patient
Clinical Educational Value (of remaining to participate)
Academic Importance of the Event
Fellows must use the text box to provide details and identify the patient.
The Program Director and the DIO will review each event of “additional service” to monitor
individual fellow, program wide, and institution wide episodes of additional duty as part of
ongoing adherence to ACGME requirements.
E. Ensuring Compliance with Duty Hours Policy
a. Fellow Reporting: Fellows are required to report their duty hours weekly in
MedHub, and they are highly encouraged to do so more frequently (daily, if
possible). If fellows become concerned that they are approaching the limits of the
duty hour policy and are at risk for a violation, they are required to report this
information immediately to their supervising faculty members and the residency
program chain of command (chief fellows, associate program directors, and/or
program director). The same reporting expectations apply to fellows who are
experiencing fatigue to a degree that may compromise patient care.
b. Monitoring: The program coordinator will review weekly the duty hour reports of all
Fellows. If there are incomplete duty hours, then the program coordinator will
promptly send reminder(s). Any violations will be investigated and addressed
individually by the program director. The GMEC will also monitor programs by
asking fellows to report any problems to the DIO, the Associate Dean for GME, or
the Ombudsmen.
c. Program Reporting: The program director will report all information related to duty
hour violations and concerns during: (1) annual program review meetings; (2)
internal reviews of the program by the institution; and (3) as required by the
GMEC, ACGME, and RRC.
38
Internal moonlighting (within SHC/LPCH) by an ACGME trainee is not allowed per institutional
policy (http://med.stanford.edu/gme/policy/).
External moonlighting (outside of SHC/LPCH) by an ACGME trainee is permitted with the
following restrictions and requirements:
1. The Program Director must approve the moonlighting schedule of the trainee. In
general, such activity cannot take place:
o Monday through Friday between the hours of 8:00 am and 6:00 pm.
o On weekends or evenings when the resident is on call.
Violations will immediately be reported to the GME Office.
2. Moonlighting must not interfere with the health, clinical responsibilities, or research
endeavors of the trainee.
3. In the event that moonlighting is determined to be compromising patient care or
interfering with the goals of the training program, this fact is immediately brought to the
attention of the involved trainee and remedied.
4. The trainee should be aware that any moonlighting activity is beyond the scope of the
Residency Program. The trainee is, therefore, not covered by the institution’s medical
malpractice insurance for such activities.
5. Moonlighting must be logged in MedHub per institutional policy. Hours worked while
moonlighting are included when determining trainees’ compliance with the 80 hour work
week limit and requirements for time off.
MOONLIGHTING POLICY
39
Coverage Policy for Emergencies/Illness; Jeopardy Schedule
A Jeopardy Schedule including first and second-year trainees is generated at the beginning
of each academic year. This schedule is created so that fellows on research or elective
months may provide coverage for fellows on Stanford/VA consults in the event of an
unexpected illness or family emergency. Jeopardy coverage will primarily be used to cover
for indisposed fellows who are on inpatient or consult rotations.
Fellows assigned to jeopardy must be available and accessible to provide coverage at any
time in the event of an emergency. Once the jeopardy schedule is established, fellows may
swap jeopardy periods with other fellows, but changes must be made among fellows;
please update the Fellowship Coordinator at least thirty (30) days in advance. These
changes must also not interfere with jeopardy coverage during ACR and UCSF Board
Review (fellows attending ACR are ineligible for jeopardy coverage during ACR and UCSF
Board Review conferences).
If a fellow wishes to go to a conference or go on vacation during his/her scheduled jeopardy
time, that fellow must find another fellow to cover jeopardy while s/he is away. This includes
weekend days within the jeopardy period.
What a Fellow Should Do in the Case of a Personal Emergency or Illness
Fellows unable to work or fulfill their duties due to minor illness or emergency are required
to follow this procedure:
Email or leave a voice message as soon as possible with the Fellowship Coordinator with
the following information:
· The approximate amount of workdays that will be missed
· Any services/rotations that will be impacted by the absence
· Any attending(s) and/or nurse coordinator(s) who should be notified of the absence
FELLOWS CROSS COVERAGE POLICY (JEOPARDY)
40
For weekend/ in the absence of the Fellowship Coordinator:
· Contact attending(s) and/or nurse coordinator(s) directly and notify them of the
absence.
· With the attending, determine if the Jeopardy Fellow will be needed and contact the
Jeopardy Fellow
· Email or leave a voice message with the Fellowship Coordinator so that the absence
can be recorded.
What a Fellow Should Do in the Case of a Jury Duty Summons
Fellows summoned to Jury Duty are required to follow this procedure:
1. As soon as the summons has been received, the fellow must notify the Fellowship
Coordinator, and any mentors, attendings and/or nurse coordinators who may be
impacted by the absence. At that time, the fellow must also provide the dates and
times when s/he is likely to be summoned.
2. Fellows must provide the original summons to the Fellowship Coordinator. A copy of
this summons will be kept in the fellow’s file.
3. The fellow must be sure to reschedule any conferences or clinics s/he was
scheduled to present at or attend during their Jury Duty term.
Fellows are expected to adhere to the highest standards of quality, providing documentation
and communication that allows for continuity of care, assuming responsibility for their own
patients, providing the highest level of care when covering for other Fellow’s patients and
willingness to assume another Fellow’s duties when appropriate - such as a result of
emergency, illness, presentation at a conference, or conflicting professional duties.
Behavior that deviates from these standards should be reported to the PD and may result in
disciplinary action.
PROFESSIONALISM AND COLLEGIAL BEHAVIOR
41
The program adheres to all policies and procedures as governed by the Stanford GME
Department regarding feedback and evaluation of both Faculty and Fellow trainees. All
such feedback and evaluation is strictly confidential and reprisal is forbidden. In the event
of feedback between Fellows, Fellows are encouraged if appropriate to first discuss with
their colleague Fellow. If they feel uncomfortable doing so or feel that their observations will
be of value to the overall evaluation of that Fellow, they should discuss them with the
Program Director. The Program Director is available by email, cell phone and/or pager.
Fellows should feel comfortable calling at any time to discuss any issue regarding the
Fellowship. If Fellows feel uncomfortable discussing issues with the Fellowship Director,
they can speak with the Chief of Rheumatology or the GME Office or both. Feedback and
criticism are encouraged and there is a strict open door policy regarding access to the
Program Director. However, such information should be constructive, professional and
designed to improve performance of Faculty, Fellows or the overall Fellowship program.
In the event that a Fellow does not wish to provide feedback to their colleague Fellow or has
done so and continues to be concerned, the Program Director will generally enact the
following protocol:
1. Review the case or concern.
2. If confidentiality permits, talk with the Fellow on whom the concern is based, so as to
hear his/her side of the story.
3. Find out whether the concern expressed pertains to other Fellows as well – i.e.,
whether this is a systemic or common issue and discuss with others as appropriate.
4. If appropriate make recommendations for improvement to the Fellow(s) on whom the
concern was raised
5. If applicable, modify the Policies & Procedures Manual to reflect the
recommendation(s).
6. Ask all Fellows and Faculty to monitor adoption of the recommendation(s).
7. Should the recommendation(s) not be uniformly adopted by all Fellows, return to the
second step with those who do not adopt it.
FEEDBACK AND EVALUATION OF FACULTY AND COLLEAGUE FELLOWS
42
Fellows are required to attend all mandatory conferences (outlined below) and must
maintain an 85% annual attendance rate. A sign in sheet will be present at each
conference so that attendance can be monitored. Failure to adhere to this standard will
result in disciplinary action and will be cited in the Fellow’s review, which typically occurs
every 4 months. Fellows are required to sign in for each of these activities and cannot have
others sign in for them.
Fellows are excused for illness, physician visits, vacation or educational leave or medical or
family emergencies.
If a Fellow is caring for a critically ill patient or a rheumatologic emergency, they should
contact the Program Director or the on call Faculty member and inform them. This will be
noted on the attendance sheet.
If a Fellow is unable to attend because of planned vacation, attendance at a rheumatology
educational program or because of a scheduled job interview, they must obtain approval
from the PD in advance. This will be noted on the attendance sheet.
Required Educational Conference Schedule
Grand Rounds - Every Thurs, 5:00pm-6:00pm, 900 Blake Wilbur Road, 1st Floor
Conference Room. Presentations will alternate between Fellows and Faculty. Community
physicians may request to present a case to obtain feedback from the larger group, and in
this case, accommodations to the schedule will be made. All decisions related to
presentations must be discussed with the Consult Attending. Fellows should be prepared to
discuss the case before the start of Grand Rounds. Please see the Faculty Supervision
Policy for details of Faculty expectations.
Journal Club – Every Friday, Noon-1pm, 900 Blake Wilbur, First floor Conference Room or
CCSR Bldg. One Fellow and one Faculty member will present a paper of interest.
Approximately one JC per month will have at least one of the presentations address the
topic of ACR, EULAR or other governing body “Guidelines.” This will insure fellows and
faculty practice evidence-based medicine.
Friday Conference Core Curriculum Series - Every Friday, 10:45-11:45pm, 1000 Welch
Road, Suite 315. Fellows’ attendance is tracked.
CONFERENCE ATTENDANCE
43
Radiology Review – Once a month with Drs. Kate Stevens and Geoff Riley, Musculoskeletal
Radiology Reading Room, first floor SUH. Every other month Michelle Nguyen holds Radiology
sessions at the VA.
Annual ACR Meeting (except the On-Call Fellow, see Travel Policy), usually held in
October/November.
Division Retreat (1-2 days annually).
Annual post ACR and EULAR Review Conferences – 6:30- 8pm, one month following
conclusion of the conference, typically hosted by Dr. Vibeke Strand.
UCSF Board Review Session – Fellowship pays for 2nd year Fellows, held in August
Annual Knowles’s Lecture – Fellows attendance required, held in April/ May
Other: Fellows who seek USSONAR Certification will be at their own expense, this is not an
ACGME requirement.
In-Service Exam
The ACR in Service Exam takes place in March of each year.
Fellows are required to take the annual in service exam. Exceptions: illness, medical
emergency.
Fellows will not be permitted to take vacation or educational leave on the day of the exam.
44
Year One
- Presenting articles at Journal Club when assigned
- Organizing and Leading Grand Rounds while on Consult Service & presenting a
case alternating with Faculty.
- Choosing a Career Mentor by October 1st, and meeting at least quarterly with the
Career Mentor to help facilitate choosing a scholarly project and mentorship for said
project.
- Presenting a formal plan for scholarly activity in Year Two. If a Fellow chooses the
Clinician Investigator Path, he/she will be expected to present a plan that would
include hypothesis, aims, research design, expected results and timeline. If a Fellow
chooses the Clinician Educator Path he/she will be expected to present a plan that
includes aims and a timeline. Fellows in the Clinician Educator Path will have a
customized clinic schedule composed of required and elective clinics. They will still
be required to have a Scholarly Project and a Faculty Mentor. Fellows in either path
will be required to present their proposals at a Friday noon conference in a 30-
minute format in the spring of the 1st year.
- Participating in a Faculty–Fellow quality improvement project.
Year Two
In addition to the requirements for Year 1, Year 2 Fellows are expected to engage in
scholarly activity. The proportion of time Fellows will spend in each of these activities will
depend on which of two pathways they choose. Year 2 Fellows in either path will be
required to present their proposals at a Friday Noon Conference in a 60-minute format in
the spring of the 2nd year.
SCHOLARLY ACTIVITIES
45
Clinician Investigator Path (Path 1)
Stanford University has a rich history of innovation and discovery in the basic sciences,
clinical sciences, and in translational medicine. A major goal of our Fellowship program is to
recruit, educate and where possible retain talented Fellows who will enter careers as long-
term clinician investigators. This path is designed for Fellows who plan a career as
physician scientists in either basic lab investigation or clinical investigation. They will be
expected to continue their research training in a 3rd and probably 4th year as part of the T32
Training grant. Details of the T32 Program, and its educational pathways and objectives,
can be found in the funded grant proposal.
Fellows in Path 1 will:
- Identify a mentor in Year 1.
- Meet regularly with the mentor during year 1 to design a proposal that is feasible to
complete during the training period
- Present quarterly updates on their scholarly project(s) to their Scholarly Mentor who
will report their progress at Faculty Division meetings.
- Give semi-annual presentations at the weekly Journal Club.
Fellows who fail to progress will meet with the PD and Faculty members to ensure that they
succeed. It is expected that their project(s) will lead, in a timely manner, to presentations at
national meetings; publications; creation of novel data sets, reagents, repositories or
educational materials; and ultimately to independent fellowship and grant applications.
Typical clinical responsibilities in Year 2 will include one or two ½ day continuity clinics on
Tuesday afternoons (the second would be “Selectives”, and reduced requirements for
consult service. Additional clinical activities must be approved by the Mentor and may be
assigned by the PD if clinical deficiencies are found to exist.
Clinician Educator Path (Path 2)
This pathway is designed for Fellows preparing for a career as clinicians and teachers in
which they will spend the majority of their time caring for patients with rheumatic diseases
and/or teaching medical students, residents, Fellows, support staff and colleagues to do the
same. They will complete their training at the end of two years. Fellows in Path 2 will be
expected to participate in significantly more clinical activity than fellows in Path 1. This will
include required clinics, elective specialty clinics, potential for educational coursework and
training in ultrasound diagnostics, and additional experiences on the consult service. Path 2
Fellows will be required to pursue scholarly activities. Their project(s) are expected to be
less rigorous than those pursued by Path 1 Fellows given the larger amount of time devoted
46
to clinical training. Projects are expected to be developed in Year 1 and to start no later than
July 1 of year 2. Projects must be approved by their Scholarly Mentor and the PD.
Fellows in Path 2 are expected to present monthly (at a minimum) updates on their
scholarly project(s) to their Scholarly Mentor who will report their progress at Faculty
Division meetings. They will be asked to give semi-annual presentations at the weekly
Journal Club. Fellows who fail to progress will meet with the PD and Faculty members to
ensure that they succeed. Their projects might include as examples: review articles, case
reports, data base studies or descriptive analyses, quality outcomes or quality improvement
studies, or patient education or community based interventions. Their project(s) must be
approved by their Scholarly Mentor and the PD.
Mentoring Program
Several of the faculty have volunteered to serve as mentors for fellows. Mentoring profiles
for each of those faculty will be sent to the new fellows in the first two months of fellowship.
By October 1, all 1st year Fellows will choose or be assigned a Career Mentor. The goal of
the Mentor is to guide, direct and assist the Fellow throughout the training period. Fellows
may change mentors at any time, pursuant to approval by the Program Director. Faculty
mentors are expected to meet with their fellow mentees at regular (minimum quarterly)
intervals throughout the two years of the training program.
PD – Fellows Review
Each 1st year Fellow will undergo a formal quarterly (4 months) review with the PD in
October, February, June. Each 2nd year Fellow will undergo a formal semi-annual (6
months) review with the PD in December and June. The review will include a verbal and
written summary of all summative evaluations of the Fellow that will describe:
REVIEW OF PERFORMANCE AND DEMONSTRATION OF COMPETENCIES
47
- their strengths and weaknesses;
- deficiencies an any of the Core Competencies;
- specific behaviors requiring improvement;
- a means to remediate deficiencies
- and a schedule to do so
Using the curriculum, competencies and milestones (see document “Goals, Objectives,
Structure and Curriculum”), Fellows will be advised of whether they are “on schedule” for
their clinical performance. Each Fellow will have a “portfolio” of examples of their clinical
work such as clinic and consult notes, presentations and results from their direct
observation. The Fellow is required to review his/her evaluations prior to the visit with the
PD and must list his/her strengths and weaknesses, goals and objectives for the next six
months and methods for achieving them. Progress towards meeting Scholarly requirement
will be included in the review.
Fellows with extensive deficiencies may receive a letter of reprimand, or may be placed on
probation. In these events, more frequent formal evaluations will be required until the
deficiencies have been documented to be corrected. Fellows with extensive deficiencies will
meet with the PD and GME representatives.
Direct Observation-MiniCEX
The PD and/or Key Clinical Faculty will observe each Fellow performing two complete
consultations per year. This will include direct observation of the taking of the history,
physical exam, orders and patient instructions. The PD will review his/her observations and
suggestions to the Fellow immediately following the observation. Included in this session
will be specific behaviors that the PD feels needs improvement. The first CEX will occur
during the first quarter of the academic year. The second CEX will occur during the last
quarter of the academic year.
During the second CEX, the PD or Key Faculty will again observe the Fellow performing a
consultation and note areas that have improved, and those that need further improvement.
The observation will focus on meeting the six competencies with special attention on
information gathering, synthesis of treatment plan, knowledge, professionalism, practice
and systems based learning, interpersonal skills, and especially communication with the
patient. Consequences of unsatisfactory performance and resolution of disputes are
outlined below. Additional evaluations may be required, at the discretion of the PD.
48
Evaluation of Fellows
The PD, all SD, and all KCF Faculty will complete standard written semi-annual (every 6
months) reviews of each Fellow.
Each Faculty attending on the rheumatology consult service will complete an evaluation of
the Fellow on the consult service. Midpoint evaluations (typically at the 2 week point) should
be performed to encourage “course corrections” during the consult block. Faculty must have
a face to face meeting with Fellows and Trainees at the conclusion of the rotation,
preferably on the final day of the rotation in preparation for transfer of Care.
If a Faculty member determines that a Fellow is performing below expectations, they must
inform the PD immediately.
Fellows and Faculty must review the Transfer of Care Policy and the Supervision Policy by
the beginning of each rotation.
A list of Core Competencies for each level of training may be found in the Appendix and
must be reviewed by the Fellow and PD every 3 months.
Consequences of Satisfactory or Unsatisfactory Evaluation
Upon receipt of satisfactory evaluations and compliance with all other terms of the Stanford
University Hospital House Staff manual
http://med.stanford.edu/content/dam/sm/gme/policy/PP2017-2018_v9.pdf Policies and
Procedures, each Fellow should expect to continue to the level of training agreed upon
when the Fellow was recruited, unless given 4 months notice (if possible) from the
department that advancement to the next level of training is not to take place at the
anticipated time. Reasons for lack of advancement must be given to the Fellow both
verbally and by written notification. While advance written notice is preferable, an
unsatisfactory evaluation may result in a decision adversely affecting the Fellow at any time
and without advance notice, such as probation, non-advancement, non-renewal or
immediate termination. In such instance, the Fellow shall be informed of the reasons for that
decision both verbally and by written notification by the PD.
The PD of any service to which the Fellow may consult may be notified of the existence of
any current probation or other performance-related issue of which the Fellow has been
49
apprised. Unless circumstances warrant immediate termination, Fellows will typically have
an opportunity to remediate unsatisfactory performance. Corrective actions can include:
(1) repeating one or more rotations; (2) participation in a special remedial program; (3) academic probation; (4) termination.
With respect to academic probation, the program will determine the length of the
probationary period, and what the resident must accomplish to be removed from the
probation. In general, the probationary period will not extend past the end of the current
agreement year, unless the agreement ends within three months, in which case the
program has the option of extending the probationary period into the next agreement year,
but the extension shall not exceed three months. Any house officer agreement that has
been issued by a program for a subsequent training year will be considered invalid and
withdrawn until the resident has fulfilled the probationary requirements imposed in the
current training year and successfully been removed for probation. At the time the house
officer completes a period of probation, the program has the following options to:
(1) allow the Fellow to complete the remainder of the training year; (2) reappoint the Fellow for the next year, where applicable; (3) not reappoint for the next year (4) immediately terminate the Fellow’s contract for the current training year.
If a Fellow disagrees with an evaluation or an adverse decision based on the evaluation, the
Fellow shall have a right to meet with the cognizant program director or committee making
the decision, to hear the reasons for the decision, and to respond to them verbally or in
writing. If after such meeting the Fellow wishes to appeal the adverse decision, the Fellow
may do so through the mechanism for resolution of disputes outlined below. Fellows may
not appeal a negative performance evaluation, beyond discussions with the cognizant
program director or committee, unless the negative evaluation also results in some adverse
action such as academic probation or the imposition of a remediation program which may
be appealed to Level 2 only.
Except in cases involving termination, the Fellow may (in the discretion of the program
director in consultation with the Medical Director, Education) be permitted to continue in the
fellowship program pending such appeal. If the Fellow is permitted to continue in the
50
program, the Fellow may be assigned to a non-patient care rotation, unpaid leave or
observation status.
Resolution of Disputes
http://med.stanford.edu/content/dam/sm/gme/policy/PP2017-2018_v9.pdf#page=20
Anonymously Report a Concern
You may use this form to anonymously report concerns specific to your residency training
program (such as duty hour violations). http://med.stanford.edu/gme/housestaff.html. To
report concerns that relate to broader hospital compliance issues such as illegal actions,
financial reporting, internal accounting controls, audit, fraud, waste, and abuse, please call
the compliance hotline for SHC (anonymity maintained): 1-800-216-1784.
All form submissions are anonymously delivered directly to the Department of
Graduate Medical Education. GME takes all concerns very seriously.
51
Evaluation of the Faculty and Program Director (PD)
MedHub evaluations will be sent to Faculty quarterly for First Year Fellows; semi-annually
for 2nd Year Fellows.
It is essential that Fellows give Faculty honest and thorough evaluation.
Because of the size of the program, anonymity becomes difficult and Fellows may be
reticent to give constructive criticism, despite the strict policy of non-reprisal. Thus, written
evaluations will be summarized by the GME office, and specific comments or suggestions
will be de-identified.
Faculty performance reviews will be discussed semi-annually with the PD and each Faculty
member. Specific areas for improvement will be identified and Faculty are expected to
progress towards meeting them at the next review. If a Faculty member fails to achieve at
least a 3.5 score (0-5), they will be counseled and required to attend a Faculty development
course. Faculty who consistently receive poor evaluations or who refuse to remediate may
no longer be allowed to serve as clinical mentors to Rheumatology Fellows.
52
Key Clinical Faculty and Faculty Focus Group
o Attend in the Clinics and Consult Service
o Give constructive criticism and feedback to Fellows privately
o Discuss observations and evaluations of Fellows with the PD
o Attend PEC meetings for the Fellowship, 1x year
o Attend CCC meetings the annual Fellowship program, 2x year.
o Give the Fellows a 30-45min synopsis of their research work, with emphasis
on ongoing translational research and/or clinical studies at a time specified by
the PD
o Host the incoming Fellows for a brief visit in the lab or research center if
asked
o If asked by the Fellow or if assigned, serve as a Scholarly Mentor
assist them in the preparation of an original research study
meet with them monthly to monitor progress.
assist them in prep of their required scholarly activities for the year
meet with the PD and Fellow quarterly to update scholarly progress
o Give a minimum of at least 1 lecture per year at the Tuesday Core Curriculum
series
o Attend one of three weekly educational conferences (Friday Core
Conference, Grand Rounds, Journal Club on a regular basis (80%
attendance rate unless excused)
o Attend an annual Faculty development session led by Medical educational
experts twice a year
o Interview Fellowship candidates and participate in social events related to
recruitment
o Maintain a minimum standard of competency and meet the evaluation
requirements for excellence in teaching
HOW THE FACULTY, KEY CLINICAL FACULTY AND FACULTY FOCUS GROUP
SUPPORT/CONTRIBUTE TO THE FELLOWSHIP
53
Sign off on all resident/fellow evaluations in MedHub
Letters of recommendation for Fellows
Verify procedure logs
Supervise QI projects
Semi-annual face to face meetings and end of fellowship meetings for 2nd years
Quarterly evals face to face meetings for 1st year fellows
Vacation requests
Monitor electives
Manage correspondence for ACR PD list serve
Monitor duty hour violations
CLER site visits
Develop Fellows Clinics and Consult schedules
Develop and arrange Noon Conference curriculum and speakers, attend each week
Organize radiology conferences at Stanford and VA
PEC meeting and action plan
CCC meeting and reporting, 2x per year
Fellow recruitment: application review, interviews, overview and close-out presentations,
rank list submission
Mentoring program supervision
Organize graduation/welcome for Fellows
Program specific orientation for new Fellows
PROGRAM DIRECTOR (PD) RESPONSIBILITIES (SHARED WITH ASSOCIATE PROGRAM
DIRECTOR)
54
Weekly PD/Coordinator/APD meetings
Monthly GME PD meetings
Semi-annual Rheum PD national meetings
Teach and observe Fellows mini-CEX, 2x per year
Yearly cross-program evaluations with assigned fellowship program
Residency fellowship information sessions for Internal Med
Meetings with IM PD, 2x per year
Proctor In-service training exam
Sign off on new Fellows contracts
Complete ACGME surveys, GME –FasTrack surveys, CME Census surveys
Revise Fellows’ Policy Handbook
Lead and organize Faculty Development Topics at Faculty Division meeting(s)
Organize Annual Program Review with self-study SWOT analysis
55
All Fellows are required to complete a minimum of two years of training and demonstrate all
ACGME mandated competencies.
As Stanford is a leading research institution, Fellows are given the opportunity to pursue an
additional 1-2 years of research training to complement their two initial clinical years and
prepare them for a career in investigation. To encourage this path, an application is
available for all fellows in the NIH Sponsored T 32 Training Program will be held for all
Fellows who (i.) meet NIH qualifications for funding; (ii.) complete the initial two clinical
years of Fellowship training; (iii.) meet all competencies; and (iv.) enter the Clinician
Investigator Pathway with a defined project and mentor. Funding for a second year of T32
training will be dependent on progress and availability of grant slots.
Changing from the Clinical Educator or Clinician Investigator Path to
Another Path
By December 1 of Year 1, Fellows must declare their intention to either complete the
program in two years (Clinician Educator Path) or extend their Fellowship experience &
accept a position for an additional 1-2 years in the Research Training Program. (Clinician
Investigator Path). Those who choose the Clinician Educator Path continue and expand
their second year clinic schedule to gain crucial experience in the ongoing care of patients
with chronic autoimmune diseases. Those who choose the Clinician Investigator Path will
spend the bulk of their time pursuing advanced research training in either basic lab or
clinical science. In order to qualify for the Investigator Path, a Fellow must demonstrate
sufficient progress towards a research project by March of their First Year at their quarterly
Research Review with the Program Director and their Scholarly Mentor. The PD and
Mentor must be assured that the Fellow will spend at least 85% of their time in Year 2
engaged in supervised, productive, research activity. Should this not be the case, the
Fellow will enter the Clinical Educator Track and will not be eligible for funding for additional
years of training at Stanford.
DURATION OF FELLOWSHIP TRAINING
56
Stanford rheumatology fellows are educated through a mixture of didactic lectures,
outpatient clinical experiences, and inpatient consult services. Fellow typically attend weekly
outpatient clinics at 3 sites: Stanford University Medical Center; Santa Clara Valley Medical
Center (SCVMC), and Palo Alto VA Hospital (PAVAMC). Fellows also rotate through 2
inpatient consult services: SCVMC and a combined consult service covering Stanford
University hospital and PAVAMC. Vacation time is used in 1-10 working day increments,
typically when a trainee is not scheduled for inpatient consult months. Second year fellows
choose between 2 different career tracks that each meet ACGME Guideline: Clinician
Investigator and Clinician Educator Tracks. Because these 2 tracks offer unique educational
and research offerings, we have included the typical schedule for each of these 2 tracks
below.
Consult Services
Month SUH/VAH SCV
July Second yr fellow #1 Second yr fellow #2
August Second yr fellow #2 First yr fellow #2
Sept First yr fellow #1 Second yr fellow #2
Oct Second yr fellow #1 First yr fellow #1
Nov First yr fellow #2 First yr fellow #1
Dec First yr fellow #1 First yr fellow #2
Jan First yr fellow #2 First yr fellow #1
Feb Second yr fellow #1 First yr fellow #2
March First yr fellow #2 First yr fellow #1
April First yr fellow #1 First yr fellow #2
May First yr fellow #2 First yr fellow #1
June First yr fellow #1 First yr fellow #2
STANFORD BLOCK DIAGRAM FOR RHEUMATOLOGY FELLOWS
57
Total Service per Fellow
SUH = Stanford University Hospital
SCV = Santa Clara Valley Medical Center
VAH = Veteran’s Administration Hospital
Clinical Services
Clinics per Fellow according to year
Year of Fellowship SUH VAH SCV
One* 2/ wk.[Mon AM, Tues PM, or Wed PM]
2/ wk.[Wed AM & Thurs AM] 1-3/wk.ⱡ
Two* 1-7 per wk.₂ 0-1/ wk.[Thurs AM] 0-3/wk ⱡ
ⱡ 3 clinics/wk when on SCV consult service; 0-1/wk when not on SCV consults. ₂ Clinician Investigator path =1- 2/wk. Clinician Educator path = 6-7/wk. * Subject to change as electives are developed.
Note: Electives vs. Required Clinics
1 Required Clinics
a. Continuity Clinics @ SUH & VAH
b. Rheum-Derm (Scleroderma and Myositis) Drs. Chung & Fiorentino—x ~2-3
mos.
c. Dr. Weyand (Vaculitidies)
d. VMC Clinics with Drs. Bush, Burkham, Marvi and Sharp
Yr. 2017-2018 SUH/VAH SCV
1st Year: First yr fellow #1 4 months 5 months
1st Year: First yr fellow #2 5 months 4 months
2nd Year: Second yr fellow #2
1 month 2 months
2nd Year: Second yr fellow #1
3 month 1 months
58
2 Elective Clinics = lengths TBD
a. Medical Dermatology
b. Women’s Clinic VAH
c. Stanford Orthopedics
d. Sports Med/Medical Orthopedics
e. PM& R
f. Pedi Rheum
g. Private Rheum. Practice
h. Podiatry
i. Ophthalmology
j. Ultrasound and/or Musculoskeletal Radiology
59
Clinic Schedule – SUH and LPCH
Derm/Rheum Clinic, RWC Campus
July 1st – June 30th
Mon PM Redwood City Campus
Jeopardy Fellow
Mon AM Continuity Clinic
Tues PM Continuity Clinic
Wed PM Continuity
Clinic
Thurs PM Specialty Clinic [Vasculitis]
First yr Fellow #1
First yr Fellows #1 and 2
First yr Fellow
# 2
Jeopardy fellow
60
PAVAMC Clinic Schedule
Mon Tues Wed AM Thurs AM Fri
AM -------- --------- First yr Fellow #2
First yr
Fellow #1
Second yr Fellow #2
OR Second yr Fellow
#1(alternate weeks July –
mid September)
Then Second yr Fellow #1
weekly
First yr Fellow #2
First yr Fellow #1
________
PM ------------ -------------- ----------------- ------------- -------------
61
SCVMC Clinic Schedule
Clinic Schedule SCVMC – Fellow on call for SCV
Mon Tues Wed Thurs Fri
AM ----------- ------------ ----------- ------------ -----------
PM Fellow ------------ Fellow ------------ Fellow
Clinic Schedule SCVMC – Fellow not on call for SCVMC or SUH*
Mon Tues Wed Thurs Fri
AM ------------ ------------ ----------- ------------ -----------
PM ------------ ------------ Elective Fellow
------------ ----------
Note: When a Fellow is on the On Call Consult Service for SUH/VAH, they do
not attend clinic at SCVMC
*One Fellow covers one clinic/wk when not On Call for SCVMC
62
Typical First Year Fellow Clinics Schedule
Mon Tues Wed Thurs
Fri 8:30-9 Board Review every other week
July AM Continuity Clinic VA Clinic VA Clinic
Core Curriculum 10:45-11:45
noon Journal Club
Valley PM Consults Continuity Clinic Consults Consults
Consult 5-6pm Grand Rounds
August AM Continuity Clinic Consults VA Clinic VA Clinic
Core Curriculum 10:45-11:45
noon Journal Club
Stanford/ VA PM Consults
Continuity Clinic Consults Consults Consults
Consults 5-6pm Grand Rounds
September AM Continuity Clinic
VA- Women's VA Clinic
Core Curriculum 10:45-11:45
noon Journal Club
Jeopardy PM Rheum/ Derm
Continuity Clinic Valley Clinic Vasculitis
5-6pm Grand Rounds
October AM Continuity Clinic VA Clinic VA Clinic
Core Curriculum 10:45-11:45
noon Journal Club
Valley PM Consults Continuity Clinic Consults Consults
Consults 5-6pm Grand Rounds
63
November AM Continuity Clinic Consults VA Clinic VA Clinic
Core Curriculum 10:45-11:45
noon Journal Club
Stanford/ VA PM Consults
Continuity Clinic Consults Consults Consults
Consult 5-6pm Grand Rounds
December AM Continuity Clinic VA Clinic VA Clinic
Core Curriculum 10:45-11:45
noon Journal Club
Valley PM Consults Continuity Clinic Consults Consults
Consults 5-6pm Grand Rounds
January AM Continuity Clinic
VA- Women's VA Clinic
Core Curriculum 10:45-11:45
noon Journal Club
Jeopardy PM Rheum/ Derm
Continuity Clinic Valley Clinic Vasculitis
5-6pm Grand Rounds
February AM Continuity Clinic VA Clinic VA Clinic
Core Curriculum 10:45-11:45
noon Journal Club
Valley PM Consults Continuity Clinic Consults Consults
Consults 5-6pm Grand Rounds
March AM Continuity Clinic Consults VA Clinic VA Clinic
Core Curriculum 10:45-11:45
noon Journal Club
Stanford/ VA PM Consults
Continuity Clinic Consults Consults Consults
Consults 5-6pm Grand Rounds
64
April AM Continuity Clinic VA Clinic VA Clinic
Core Curriculum 10:45-11:45
noon Journal Club
Valley PM Consults Continuity Clinic Consults Consults
Consults 5-6pm Grand Rounds
May AM Continuity Clinic Consults VA Clinic VA Clinic
Core Curriculum 10:45-11:45
noon Journal Club
Stanford/ VA PM Consults
Continuity Clinic Consults Consults Consults
Consults 5-6pm Grand Rounds
June AM Continuity Clinic
VA- Women's VA Clinic
Core Curriculum 10:45-11:45
noon Journal Club
Jeopardy PM Rheum/ Derm
Continuity Clinic Valley Clinic Vasculitis
5-6pm Grand Rounds
65
Typical Second Year Fellow Clinics Schedule (Clinician Educator Track)
Mon Tues Wed Thurs
Fri 8:30-9 Board Review every other week
July AM VA-Women's VA Clinic
Core Curriculum 10:45-11:45
noon Journal Club
Jeopardy PM Rheum/ Derm
Continuity Clinic
Vasculitis Clinic
5-6pm Grand Rounds
August AM VA-Women's VA Clinic
Core Curriculum 10:45-11:45
noon Journal Club
Jeopardy PM Rheum/ Derm
Continuity Clinic
Vasculitis Clinic
5-6pm Grand Rounds
September AM VA Clinic
Core Curriculum 10:45-11:45
noon Journal Club
Valley PM
Valley Consult
Continuity Clinic
Valley Consult
Valley Consult
Consults 5-6pm Grand Rounds
October AM Elective Elective Valley Clinic VA Clinic
Core Curriculum 10:45-11:45
noon Journal Club
Elective PM Elective Continuity Clinic Elective Elective Elective
5-6pm Grand Rounds
66
November AM Elective Elective Valley Clinic VA Clinic
Core Curriculum 10:45-11:45
noon Journal Club
Elective PM Elective Continuity Clinic Elective Elective Elective
5-6pm Grand Rounds
December AM Consult VA Clinic
Core Curriculum 10:45-11:45
noon Journal Club
Stanford/ VA PM Consult
Continuity Clinic Consult Consult Consult
Consult 5-6pm Grand Rounds
January AM Elective Elective Valley Clinic VA Clinic
Core Curriculum 10:45-11:45
noon
Journal Club
Elective PM Elective Continuity Clinic Elective Valley Clinic
5-6pm Grand Rounds
February AM Elective Valley Clinic VA Clinic
Core Curriculum 10:45-11:45
noon Journal Club
Elective PM Elective Continuity Clinic Elective Elective
5-6pm Grand Rounds
March AM Elective Valley Clinic VA Clinic
Core Curriculum 10:45-11:45
noon Journal Club
Elective PM Elective Continuity Clinic Elective
Vasculitis Clinic Elective
5-6pm Grand Rounds
67
April AM VA Clinic
Core Curriculum 10:45-11:45
noon Journal Club
Valley PM
Valley Consult
Continuity Clinic
Valley Consult
Valley Consult
Consult 5-6pm Grand Rounds
May AM VA-Women's VA Clinic
Core Curriculum 10:45-11:45
noon Journal Club
Jeopardy PM Rheum/ Derm
Continuity Clinic
Vasculitis Clinic
5-6pm Grand Rounds
June- 1st half AM
VA-Women's VA Clinic
Core Curriculum 10:45-11:45
noon Journal Club
Jeopardy PM Rheum/ Derm
Continuity Clinic
Vasculitis Clinic
5-6pm Grand Rounds
June- 2nd half AM
Continuity Clinic Elective
Valley Clinic VA Clinic
Core Curriculum 10:45-11:45
noon Journal Club
Elective PM Elective Elective Elective Elective
5-6pm Grand Rounds
68
Typical Second Year Fellow Clinics Schedule (Clinical Investigator Track)
Mon Tues Wed Thurs
Fri 8:30-9 Board Review every other week
July AM Core Curriculum 10:45-11:45
noon Journal Club
Research PM Continuity Clinic
5-6pm Grand Rounds
August AM Valley Clinic VA- Women's
Core Curriculum 10:45-11:45
noon Journal Club
Jeopardy PM Continuity Clinic Vasculitis
5-6pm Grand Rounds
September AM Consults Consults Consults Consults
Core Curriculum 10:45-11:45
noon Journal Club
Stanford/ VA PM Consults Consults
Continuity Clinic Consults Consults
5-6pm Grand Rounds
October AM Valley Clinic VA- Women's
Core Curriculum 10:45-11:45
noon Journal Club
Jeopardy PM Rheum/ Derm
Continuity Clinic Vasculitis
5-6pm Grand Rounds
69
November AM Consults Core Curriculum 10:45-11:45
noon Journal Club
Valley PM Consults Continuity Clinic Consults
Consults 5-6pm Grand Rounds
December AM Valley Clinic VA- Women's
Core Curriculum 10:45-11:45
noon Journal Club
Jeopardy PM Rheum/ Derm Vasculitis
5-6pm Grand Rounds
January AM Consults Consults Consults Consults
Core Curriculum 10:45-11:45
noon Journal Club
Stanford/ VA PM Consults Consults
Continuity Clinic Consults Consults
Consults 5-6pm Grand Rounds
February AM Core Curriculum 10:45-11:45
noon Journal Club
Research PM Continuity Clinic
5-6pm Grand Rounds
March AM Core Curriculum 10:45-11:45
noon Journal Club
Research PM Continuity Clinic
5-6pm Grand Rounds
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April AM Core Curriculum 10:45-11:45
noon Journal Club
Research PM Continuity Clinic
5-6pm Grand Rounds
May AM Core Curriculum 10:45-11:45
noon Journal Club
Research PM Continuity Clinic
5-6pm Grand Rounds
June AM Core Curriculum 10:45-11:45
noon Journal Club
Research PM Continuity Clinic
5-6pm Grand Rounds
Electives are typically 2-4 weeks
71
Faculty: Yashaar Chaichian, MD
Title: Clinical Assistant Professor
Contact: 1000 Welch Road, Suite 203
MC 5755
Palo Alto, CA 94304
Office: (650) 498-5630
Fax: (650) 723-9656
Email: [email protected]
CAP Profile: https://profiles.stanford.edu/intranet/yashaar-chaichian
Current Research and Scholarly Interests
My main clinical and research interests lie in autoimmune pulmonary diseases. These
conditions, which include interstitial lung disease and pulmonary hypertension in the context
of systemic rheumatic disease, are increasingly recognized as important contributors to
morbidity and mortality in our patient population. I am interested in helping develop ways to
better coordinate the multidisciplinary management that is required to optimally take care of
these patients. I am also interested in participating in collaborative clinical and translational
research with other rheumatologists as well as pulmonologists that will seek to improve our
understanding of the pathogenesis, diagnosis, and treatment of these conditions. Lastly, I
am passionate about teaching and look forward to working with rheumatology fellows and
other trainees here at Stanford.
FACULTY AND PROGRAM RESEARCH LINKS
72
Faculty: Lorinda Chung, MD, MS Title: Associate Professor of Medicine and
Dermatology Contact: 3801 Miranda Ave.
Palo Alto VA Health Care System
Palo Alto, CA 94304
Office: (650) 493-5000 ext. 62042
Cell: (650) 575-8008
Fax: (650) 849-1213
Email: [email protected]
CAP Profile: https://med.stanford.edu/profiles/stanford/Lorinda_Chung/ Website: http://stanfordhospital.org/autoimmune
Research Interests My research interests focus on all aspects of systemic sclerosis and dermatomyositis. I am
currently involved in clinical, translational, and epidemiologic research in these areas, and
dedicate a substantial portion of my research time to investigator-initiated and multi-center
clinical trials of novel therapeutics for the treatment of systemic sclerosis and
dermatomyositis. I co-attend the Rheumatologic Dermatology Clinic with David Fiorentino
from Dermatology and we collect clinical data, blood and skin biopsies from our patients
during clinical visits. We also collaborate closely with multiple divisions in the Department
of Medicine (Pulmonary, Cardiology, Gastroenterology) in the ongoing study of molecular
and clinical responses to novel therapeutics for the treatment of these diseases, with the
goal of identifying useful biomarkers from skin and blood samples. We are especially
interested in the vascular disease related to systemic sclerosis, including investigating the
pathogenesis, biomarkers, and potential treatments for pulmonary arterial hypertension and
digital ulceration. In addition, we are currently characterizing unique clinical phenotypes
associated with dermatomyositis-specific autoantibodies.
73
Faculty: Robert Fairchild, MD, PhD
Title: Assistant Clinical Professor
Contact: 1000 Welch Road, Suite 203
MC 5755
Palo Alto, CA 94304
Office: (650) 723-6961
Fax: (650) 723-3059
Email: [email protected]
CAP Profile: https://profiles.stanford.edu/intranet/robert-fairchild
Research Interests Dr. Fairchild specializes in the diagnosis, evaluation and management of rheumatologic
diseases. He has a particular interest in musculoskeletal ultrasound and heads the Division
of Immunology and Rheumatology's Diagnostic and Interventional Musculoskeletal
Ultrasound Clinic. Dr. Fairchild, received his Ph.D. from Georgetown University, and his
M.D. from Columbia University College of Physicians and Surgeons. He completed
internship and residency in the Department of Medicine at Stanford University. He
continued on at Stanford, completing his fellowship in rheumatology and subsequently
joined the faculty of the Division of Immunology and Rheumatology. He trained in
rheumatologic musculoskeletal ultrasound through the USSONAR program and is certified
in this technique through the American College of Rheumatology (RhMSUS certification).
74
Faculty: C. Garrison Fathman, MD Title: Professor of Medicine, Emeritus - Active Contact: CCSR Building, Room 2215B
269 Campus Drive
Stanford, CA 94028
Office phone: (650) 723-7887
Cell: (650) 868-4546
Fax: (650) 725-1958
Email: [email protected]
CAP Profile: http://med.stanford.edu/profiles/C_Fathman/;jsessionid=9C03DA22C2353516D237BC18EE818E94.tc-cap-07
Website: http://fathmanlab.stanford.edu/
Research Interests
Dr. C. Garrison (Garry) Fathman is Founder and Past President of the Federation of Clinical
Immunology Societies (FOCIS), Professor of Medicine and Chief of the Division of
Immunology and Rheumatology at Stanford University School of Medicine, serves as Co-
Director of the Institute for Immunity, Transplantation and Infection at Stanford. His
contributions in the cellular and molecular immunology of responsiveness and
unresponsiveness of CD4 T cells, and in developing novel models of immunotherapy, have
brought him international recognition. In particular, he is acclaimed for his establishment
and exploitation of the technologies of antigen-specific T-cell cloning and antigen specific
therapy as well as adoptive cellular gene therapy, accomplishments that have facilitated a
remarkable series of subsequent advances in understanding conventional immune
response and provided insights into future therapy of autoimmune diseases.
75
Faculty: Mark C. Genovese, MD Title: Professor of Medicine Contact: 1000 Welch RD #203
Palo Alto, CA 94304
Office: (650) 498-4528
Cell: (408) 480-7318
Fax: (650) 723-9656
Email: [email protected]
CAP Profile: http://med.stanford.edu/profiles/Mark_Genovese/
Research Interests Our research group is located in the 1000 Welch RD building, however, we utilize several
locations for the conduct of clinical studies including the Clinical Translational Research Unit
(CTRU), the former General Clinical Research Center (GCRC). We are interested in patient
oriented clinical research focus in and the the development of novel therapeutics for the
treatment autoimmune diseases and arthritis. Ongoing studies currently focus on
therapeutic interventions in Rheumatoid Arthritis (RA), Psoriatic Arthritis (PSA), and
Osteoarthritis (OA). As well there are ongoing collaborations with internal and external
investigators looking at biomarkers, and surrogates to better understand, diagnosis,
prognosis, prediction of response, and use of imaging in these diseases.
76
Faculty: Jorg J. Goronzy, MD, PhD
Title: Professor of Medicine Website: http://goronzylab.stanford.edu Contact: 3801 Miranda Ave.
Palo Alto VA Health Care System
Palo Alto, CA 94304
Office: (650) 723-9027
Email: [email protected]
CAP Profile: https://med.stanford.edu/profiles/stanford/Jorg_Goronzy/
Research Interests The Goronzy lab is interested in understanding how a functional immune system is
maintained with age, despite failing regenerative capacity and accumulating impacts by
challenges from exogenous and latent infections. We study mechanisms, at the system as
well as the single cell level, that contribute to declining immunity and to the higher frequency
of some autoimmune diseases with age. We primarily work with human blood specimens or
cell lines. Ultimately, we are trying to identify molecular pathways that can be targeted to
improve immune function.
77
Faculty: Halsted R. Holman, MD Title: Guggenheim Professor of Medicine,
Emeritus - Active Contact: 1000 Welch Road, Ste. 204
Palo Alto, CA 94305
Office: (650) 723-5906
Fax: (650) 723-9656
Email: [email protected]
CAP Profile: http://med.stanford.edu/profiles/Halsted_Holman/
Research Interests In recent years, I have been engaged in action research involving design, installation and
evaluation of better ways to care for patients with chronic disease. The underlying
assumption is that effective and efficient care of chronic disease, which differs substantially
from that for acute disease, is essential to solving the health care crisis. The primary models
are the Chronic Care Model of health care practice and the Patient Centered Medical
Home. The work has occurred in various community and academic settings. It entails
changing medical practice patterns and developing new health care programs. It also
involves aiding physicians, patients and health professional trainees to understand the
reasons for such changes and the ways to achieve them.
78
Faculty: Jison Hong, MD Title: Clinical Assistant Professor Contact: 1000 Welch Road, Suite 203
Palo Alto, CA 94304
Office: (650) 723-6003
Fax: (650) 723-9656
Email: [email protected]
CAP Profile: https://med.stanford.edu/profiles/jison-hong
Research Interests
My research interests include studying the association between cardiovascular disease and
rheumatologic conditions. I am collaborating with preventive cardiology to identify patients
with rheumatic diseases at increased risk for cardiovascular outcomes. We will be using a
multidisciplinary approach in order to try to modify their cardiovascular risk. I am also
involved in translational clinical trials in lupus that bring the innovations from our research
labs to the patients in clinic allowing for use of new therapies for disease otherwise
refractory to conventional treatment. Another area of interest is musculoskeletal ultrasound
in clinical practice. I hope to be able to use ultrasound in the diagnosis and monitoring of
response to therapy for our patients with various types of arthritis conditions.
79
Faculty: Janice Lin, MD Title: Clinical Assistant Professor Contact: 1000 Welch Road, Suite 203
Palo Alto, CA 94304
Office: (650) 498-5630
Fax: (650) 723-9656
Email: [email protected] CAP Profile: https://profiles.stanford.edu/janice-lin
Current Research and Scholarly Interests My areas of clinical and research interest involve cutaneous manifestations of rheumatic
diseases, including but not limited to psoriasis, dermatomyositis, and cutaneous lupus. I
would like to study and learn how the skin lesions offer an insight into systemic disease, and
the evolution of skin lesions such as psoriasis into inflammatory arthritis. I am also
interested in utilizing musculoskeletal ultrasound as a diagnostic and interventional tool for
our patients in rheumatology, particularly for joints that are difficult to evaluate by
conventional clinical exams. I really look forward to working with trainees in the combined
dermatology-rheumatology clinic, and the opportunities to interact with them in all the
teaching settings.
80
Faculty: Michael G. Lyon, MD, MPH
Title: Clinical Associate Professor of Medicine
Chief, Rheumatology/Allergy Section –
VA Palo Alto Health Care System
Program Director, Adult Rheumatology Fellowship Program
Contact: VA Palo Alto Health Care System
3801 Miranda Ave (111 G)
Palo Alto, CA. 94304-1290
Phone: (650) 723-7038
Fax: (650) 723-7509
Email: [email protected]
CAP Profile:
http://stanfordhospital.org/profiles/frdActionServlet?choiceId=printerprofile&fid=12691
Professional Interests/Activities
Patient care, teaching, administration, program development. The Palo Alto VA serves
veterans from throughout the Bay Area, northern San Joaquin Valley, Monterey basin, and
central Sierra foothills. The Rheumatology Section operates clinics at the Palo Alto main
campus, and at our satellite facilities in Livermore and Modesto. We care for military
veterans with a diversity of rheumatic conditions. Our section has been at the forefront of
the process of developing and evaluating innovative patient care delivery methods in
Rheumatology, among which have been group visits, telemedicine, telephone gout
management, and Arthritis Nurse Practitioner clinics.
81
Faculty: William H. Robinson, MD, PhD
Title: Associate Professor of Medicine Contact: VA Palo Alto Health Care System
Building 100, Room D4-124
3801 Miranda Ave
Palo Alto, CA 94304
Office: (650) 849-1207
Cell: (650) 465-8051
Lab: (650) 849-1245
Fax: (650) 849-1208
Email: [email protected]
CAP Profile: http://med.stanford.edu/profiles/William_Robinson/ Website: http://robinsonlab.stanford.edu
Research Interests
The Robinson Laboratory investigates the molecular mechanisms underlying rheumatic
diseases, with a focus on rheumatoid arthritis (RA) and osteoarthritis (OA). The major
objective of his laboratory is translational bench-to-bedside research, with the goal of rapidly
converting discoveries at the bench into practical patient care tools and therapies.
Candidate pathogenic molecules and pathways, identified through proteomic and genomic
analyses of human patient samples, are investigated using in vitro assays and mouse
models of disease. Based on technologies and approaches developed or co-developed by
the Robinson laboratory, clinical development programs have arisen in three areas: (i)
human trials to test tolerizing DNA vaccines for the treatment of multiple sclerosis and
autoimmune diabetes, (ii) human trials to test imatinib and other tyrosine kinase inhibitors
for the treatment of systemic sclerosis, (iii) human studies to test proteomic diagnostic tests
for RA, and (iv) a human pilot trial to test an anti-inflammatory intervention in OA.
82
Faculty: Neha S. Shah, MD
Title: Clinical Instructor/ Program Director Contact: 1000 Welch Road
Suite 203
Office: (650) 498-5630
Fax: (650) 723-9656
Email: [email protected]
CAP Profile: https://med.stanford.edu/profiles/neha-shah
Research Interests
My clinical and research interests lie in Integrative Rheumatology, healing-
oriented medicine that takes account of the whole patient, including all aspects of lifestyle. It
emphasizes the therapeutic relationship between practitioner and patient, is informed by
evidence, and makes use of all appropriate therapies, including those outside the realm of
allopathic medicine. Specifically, I am interested in exploring the impact of diet/nutrition on
inflammation as it pertains to rheumatic diseases such as rheumatoid arthritis, lupus, and
psoriatic arthritis, as well as studying the impact of other lifestyle approaches on disease
burden and quality of life of patients with rheumatic diseases. I am pursuing collaboration
with translational researchers to look at the scientific basis for control of inflammation by
adjusting the gut microbiome, herbals/botanicals (rooted in Traditional Chinese Medicine
and Ayurveda), nutritional approaches, and lifestyle interventions.
83
Faculty: Stanford Shoor, MD Title: Clinical Professor of Medicine Contact: 1000 Welch Road, Suite 203
Palo Alto, CA 94304
Office: (650) 725-5070
Cell: (408) 313-4789
Email: [email protected]
CAP: http://med.stanford.edu/profiles/Stanford_Shoor/
Research Interests I am establishing a Performance Improvement System for the Division and expanding our
clinical presence. This involves several features:
1. I am constructing a registry for the principal rheumatic disease and inserting
validated outcome measures for each into the electronic medical record. At present
a CDAI and RAPID 3 are now part of the medical record for all patients with RA and
work is starting with the STRIDE informatics group to create a registry of all patients
with RA. Within the next year it is anticipated that a similar registry and outcome
measure will be created for SLE.
2. I am piloting a novel approach to the management of chronic rheumatic diseases.
This involves substituting medical assistant, RNP and pharmacist phone and email
communications for routine follow up visits for RA. Working with the Chronic Disease
Self -Management Program, we will enhance patient self -care skills. Using RAPID
3, CDAI and patient satisfaction as outcome measures we will aim to reduce
redundant follow-up visits and utilize the appointments to improve our access to new
consultations while simultaneously increasing patient satisfaction and improving
outcome.
3. I have met with Internal Medicine and Orthopedics to establish a Multidisciplinary
Clinic for management of osteoarthritis and musculotendinous in older patients in
which outcome will be assessed in OA with a WOMAC. Working with the STRIDE
84
group we will establish a registry which will not only define quality of care but also
serve as fertile ground for investigation.
4. A clinical collaboration will be established between Internal Medicine/Primary Care
and Rheumatology to improve the care of patients with rheumatic diseases. This will
include cell phone access to a rheumatologist will be available during working hours
and piloting a weekly ½ day clinic in the Hoover annex.
85
Faculty: Samuel Strober, MD
Title: Professor of Medicine, Emeritus Chief Contact: CCSR Building
Room 2215C
269 Campus Drive
Stanford, CA 94305
Office: (650) 723-6500
Cell: (650) 575-1510
Lab: (650) 723-5544
Fax: (650) 725-6104
Email: [email protected]
CAP Profile: https://med.stanford.edu/profiles/stanford/samuel_strober
Research Interests Our interests are in the area of cellular immunology, and the regulatory interactions
between subpopulations of immune cells. In particular, we are interested in the
identification, function, and molecular mechanisms by which some subpopulations of
lymphocytes amplify the immune response and some such as natural killer T cells (NKT
cells) and regulatory T cells (Treg cells) suppress it. Investigation into interactions of the
cells during the immune response to organ and bone marrow transplants and in systemic
lupus is a major focus of the laboratory research. Developing therapeutic strategies for
clinical organ transplantation and lupus in humans based on these principles is a major
goal. Specific areas of research are as follows: (i) immune tolerance to organ and bone
marrow transplants: Immune tolerance is recognized to be the paralysis of the immune
system in its response to a given antigen, the development of anergy, or antigen-specific
suppressor cells. Our research programs are studying these mechanisms at the cellular
and molecular levels in laboratory animals and humans that are made tolerant to foreign
organ or bone marrow transplants. In the case of bone marrow transplants, the goal is to
prevent graft vs. host disease while maintaining graft anti-tumor activity. (ii) Mechanisms
of autoimmunity in systemic lupus: Many autoimmune diseases represent a breakdown
of immune tolerance to self-antigens. The mechanisms by which 1) animals develop
tolerance to self during ontogeny, 2) tolerance is broken in adult life resulting in systemic
autoimmune diseases such as lupus, and 3) tolerance can be reestablished after the
86
development of autoimmune disease are the subjects of investigation. Our laboratory is
involved in identifying those cells (NKTcells, Treg cells, myeloid derived suppressor cells)
involved in the induction and maintenance of immune tolerance with regard to their surface
receptors, effector functions, and the nature of secreted molecules which mediate their
function. We have shown that these cells are important suppressors of tumor immunity as
well as autoimmunity, and genetic abnormalities in these cells can promote systemic lupus.
87
Faculty: Paul J. Utz, MD Title: Professor of Medicine Contact: CCSR Building
Room 2215A
269 Campus Drive
Stanford, CA 94305
Cell: (650) 804-1688
Office: (650) 724-5421
Lab: (650) 724-6470
Fax: (650) 723-7590
Email: [email protected]
CAP Profile: https://med.stanford.edu/profiles/stanford/Paul_Utz/
Website: www.utzlab.stanford.edu
Research Interests Our lab is located in the CCSR building. We are interested in autoimmune diseases,
including systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), scleroderma,
myositis, primary biliary chirosis (PBC), Sjögren's disease, insulin dependent diabetes (type
I diabetes or IDDM), multiple sclerosis (MS) and mixed connective tissue disease (MCTD).
The Utz lab is comprised of approximately 12 scientists, including Postdoctoral Fellows,
Research Assistants, Undergraduate Students and Graduate Students. The focus of our
research centers on serum autoantibodies produced in a variety of autoimmune diseases.
In addition to trying to better understand the pathogenic mechanisms involved in
autoimmunity, we are interested in developing bench-to-bedside technologies, including
diagnostics and therapeutics, for human autoimmune diseases.
88
Faculty: Cornelia M. Weyand, MD, PhD Title: Professor of Medicine, Division Chief Contact: CCSR Building
Room 2225
269 Campus Drive
Stanford, CA 94305
Office: (650) 723-9027
Email: [email protected]
CAP Profile: https://med.stanford.edu/profiles/stanford/Cornelia_Weyand
Website: http://med.stanford.edu/weyand/
Research Interests The Weyand lab is interested in tissue-damaging immune responses in rheumatoid arthritis,
atherosclerosis and large vessel vasculitis. We use several preclinical models, including a
chimera model in which human synovial tissue and human blood vessels are engrafted into
immunodeficient mice. Over the last decade, we devoted special emphasis to the
remodeling of the immune system with aging, how chronic disease ages the immune
system, and how aged immune cells cause inflammation. We are interested in molecular
defects underlying the premature aging process in patients with rheumatoid arthritis,
including deficiencies in telomerase and the DNA damage sensor Ataxia Telangiectasia
Mutated (ATM). In atherosclerosis or in GCA, we study immune cells that mediate medium
vessel vasculitis and define the molecular underpinnings of the immuno-stromal interactions
that cause arterial inflammation.
89
Stanford Hospital and Clinics Spheris Dictation Instructions
To enter the dictation system from a touch tone phone:
1. Press 233 or 1-800-242-9770.
2. Enter your physician ID number followed by the # key. Do not enter leading 0’s. If
your number is 0012, enter 12.
3. Enter valid clinical area code followed by the # key:
Enter Code:
1 (Inpatient)
2 (ED)
3 (Outpatient Surgery)
4 (Inpatient Psychiatry)
Enter Clinical Area Code *
Enter your clinical area code here for reference.
If you are not sure what your clinic code is, call 3-5588
STANFORD DICTATION INSTRUCTIONS
90
4. Enter valid work type followed by the # key:
Inpatient/OPS/ED Clinic
1= Pre-op History & Physical 30= Neurodiagnostics
2= Admit History & Physical 31= Radiation Tmt Summary
3= Inpatient Progress Note 33= Clinic Visit
5= Operative Report 36= Outpatient Letter
6= Inpatient Letter 40= Radiology Report
7= Discharge Summary 57= Other Patient Specific Note
8= Transfer Off Service 58= Outpatient Psychiatry Note
10= ED Note 35= Outpatient Procedure
5. Enter 8-digit medical record number followed by the # key
6. Press 6 at any time during dictation to assign a high priority
7. Please speak the following:
Your first and last name (please spell last name)
Patient’s first and last name (please spell first and last name)
Medical Record Number (MRN)
Attending physician’s first and last name
Type of report
Date of service
****Last 4 digits of CNS number****
NOTE: You must press 2 to pause. Failure to press 2 will result in long blank spaces
in your dictation.
91
2 Dictate/Stop/Pause 77 Rewind to beginning w/auto playback
3 Short rewind and play 8 New report, same worktype
4 Fast forward 44 End job
5 Disconnect 0 Repeat job confirmation number (Job
#)
6 High Priority (STAT)
7 Short rewind and pause
TO LISTEN TO DICTATION BEFORE DISCONNECTING:
If you would like to switch to listen mode before disconnecting, complete your dictation by
pressing 8. When you are prompted for Work Type, enter *1 and then press 3 to enter listen
mode.
STANFORD HOSPITAL AND CLINICS DOCUMENTATION REQUIREMENTS:
HISTORY & PHYSICALS must be completed within 24hrs of admission or prior to an
invasive procedure.
OPERATIVE REPORTS must be completed within 24hrs of surgery.
DISCHARGE SUMMARIES must be completed within 7 days of discharge.
SIGNATURES: Title 22 requires medical records to be completed within 14 days of
the patient’s discharge.
Call Transcription at (650) 723-5588 with questions.
92
Rheumatology Fellows Conference Schedule July – December 2018
Fridays 10:45 – 11:45 am, Radiology on Tuesdays Location 1000 Welch Road, 3rd Floor Conference Room, Suite 315
Date Speaker Topic
July
07/06/18 Friday Vibeke Strand How to Select a Journal Club Article
07/13/18 Friday Jison Hong Rheumatologic Emergencies
07/17/18 Tuesday Michelle Nguyen Radiology
07/27/18 Friday Mark Genovese How to Present at Grand Rounds
August
08/03/18 Friday Alma Alikadic (10:15-11:45) Compliance Documentation Guidelines
08/10/18 Friday Stan Shoor MSK Exam with Live Model
08/17/18 Friday Neha Shah Joint Injection
08/21/18 Tuesday Kate Stevens Radiology
08/31/18 Friday PJ Utz Use & Interpretation of Lab Tests
September
09/07/18 Friday Stan Shoor Infusion Reactions/Perioperative Management of Rheum Meds
09/14/18 Friday Rob Fairchild MSK I
09/18/18 Tuesday Michelle Nguyen Radiology
09/28/18 Friday Vibeke Strand JAK/STATs
October
10/05/18 Friday Division Retreat
10/12/18 Friday Rob Fairchild MSK II
10/16/18 Tuesday Kate Stevens Radiology
10/26/18 Friday Matthew Baker IgG4 Related Diseases
November
11/02/18 Friday Rob Fairchild MSK III
11/06/18 Tuesday Bruce Cronstein Rheumatology Grand Rounds
11/13/18 Tuesday Michelle Nguyen Radiology
11/23/18 Friday Thanksgiving
11/30/18 Friday Yashaar Chaichian Lupus Part I
December
12/07/18 Friday Rob Fairchild MSK IV
12/14/18 Friday Yashaar Chaichian Lupus Part II
12/18/18 Tuesday Kate Stevens Radiology
12/28/18 Friday Winter Closure
93
Rheumatology Fellows Conference Schedule January – June2018
Tuesdays 11:45 – 12:45 pm Location 1000 Welch Road, 3rd Floor Conference Room, Suite 315
Date Speaker Topic
January
01/02/18 Winter Closure
01/09/18 Rob Fairchild MSK – Ultrasound I
01/16/18 Michelle Nguyen Radiology
01/23/18 Rob Fairchild MSK Ultrasound II
01/30/18 Neera Narang Evaluating Private Practice Career Options
February
02/06/18 Mark Genovese Part 2 - Biologics
02/13/18 Michael Marmor Maculopathy of Anti-Malarial Therapies
02/20/18 Kate Stevens Radiology
02/27/18 Rob Fairchild MSK Ultrasound III
March
03/06/18 Victoria Kelly Psoriatic Arthritis: Pathogenesis and Diagnosis
03/13/18 Rob Fairchild MSK Ultrasound IV
03/20/18 Michelle Nguyen Radiology
03/27/18 ACR In Training Exam
April
04/03/18 Bill Robinson Osteoarthritis
04/10/18 Stan Shoor Sarcoidosis
04/17/18 Kate Stevens Radiology
04/24/18 Vibeke Strand JAK/STATs
May
05/01/18 Jorg Goronzy Large Vessel Vasculitis
05/08/18 Neha Shah CAM in Arthritis
05/15/18 David Sobel Patient Centered Communication
05/22/18 Lorinda Chung Autoimmune Muscle Disease
05/29/18 Vibeke Strand Immunogenicity
June
06/05/18 Janice Lin Management of Psoriatic Arthritis
06/12/18 Michael G. Lyon Gout
06/19/18 Kate Stevens Radiology
06/26/18 Jison Hong Fellow’s Review of Program
Outline
A Competency-Based Guide to Curriculum Development
Core Curriculum
for Rheumatology Fellowship Programs UPD ATED JUNE 2015
STANFORD ADULT RHEUMATOLOGY FELLOWSHIP PROGRAM MILESTONES BASED CURRICULUM ( index of abbreviations)
CC—core curriculum + Friday pre-clinic conference CEX—standardized observed patient encounter CONCA—all continuity clinics CONCSU—Stanford continuity clinics CONCSC—scvmc clinic CONCVA—VA continuity clinic HAE—handoff evaluations INC/S—inpatient consultation services ISE—annual in-training exam JC---journal club QI—quality improvement projects RGR—Rheumatology Grand Rounds RS—research SDL—self directed learning SE—specialty electives
MILESTONES BASED CURRICULUM: STANFORD UNIVERSITY ADULT RHEUMATOLOGY FELLOWSHIP PROGRAM
MEDICAL KNOWLEDGE
Subspecialty Reporting Milestone
Rheumatology Curricular Milestones
Your Training Program
Number
By this time
(months)
The fellow should be able to
For this curricular milestone
Activities
Assessment Tools
Clinical Knowledge (MK1)
MK1Ͳ01
12 Demonstrate basic knowledge of the relevant structure and function of the musculoskeletal system, immune system and basic science for describing the pathophysiology of rheumatologic conditions.
SDL;CC;JC Multi-source assessment*;ISE
24 Demonstrate comprehensive
MK1Ͳ02
6 Acknowledge the indications for referrals to other subspecialists and ancillary services including orthopedics and rehabilitation medicine.
INC/S;CONCA;SE Multi-source asssessment
12 Independently distinguish indications for
18
Independently formulate specific consultative questions for
MK1Ͳ03
6 List relevant mechanisms of action and potential adverse effects of agents used in the management of patients with rheumatologic conditions.
INC/S;CONCA;JC;CC Multi-source; ISE
12 Explain
18 Differentiate subtle differences in
MK1Ͳ04
12
Report on
the anatomy, physiology and management of pain in patients with rheumatologic conditions.
CONCA;SE;SDL MULTI-SOURCE; ISE;CEX
18 Teach others
MK1Ͳ05
12 List
similarities and differences of the clinical presentation and management
between adults and children with rheumatic conditions.
SE;CC;SDL MULTI-SOURCE; ISE
18 Describe in detail
24 Explain the significance of
MK1Ͳ06
6 In uncomplicated cases, construct
a differential diagnosis for rheumatologic conditions, including consideration of nonͲrheumatic diseases.
SDL;CONCA;INC/S;CC MULTI-SOURCE; CEX
12
In cases demonstrating increasing complexity, construct
18
In highly complex cases, with multiͲ system involvement, construct
24 Teach others to construct
MK1Ͳ07
12 Demonstrate basic
knowledge regarding the need for preventive care in patients with rheumatic conditions.
SDL;CONCA;CC;JC MULTI-SOURCE
18 Demonstrate comprehensive
MK1Ͳ08 12 Demonstrate basic knowledge to evaluate complex rheumatic diseases in the setting of multiple
18 Demonstrate comprehensive coexistent conditions, including the effects of aging. CONCA;CC;SE;INC/S MULTI-S0URCE; CEX
MK1Ͳ09
12 Demonstrate basic knowledge of socioͲbehavioral sciences including but not limited to health care
economics and medical ethics. SE;JC;CC;CONCSC MULTI-SOURCE
24 Demonstrate comprehensive
Knowledge of Diagnostic Testing and Procedures (MK2)
MK2Ͳ01
6 Identify
indications, risks and benefits of rheumatologic diagnostic testing, including but not limited to immunoassays, synovial fluid analysis, routine blood chemistries, hematologic studies, coagulation studies, radiographs, and DXA scanning.
CONCA;CC;INC/S;SDL;
RGR;SE
MULTI-SOURCE;ISE
12 Describe
18 Differentiate
24 Teach
MK2Ͳ02
12 Explain major findings and interpretation of rheumatologic diagnostic testing, including
but not limited to immunoassays, synovial fluid analysis, routine blood chemistries, hematologic studies, coagulation studies, radiographs, and DXA scanning.
CONCA;CC;INC/S;SDL;
RGR;SE
MULTI-SOURCE;ISE
24 Teach others about
MK2Ͳ03
6 List
indications, risks and benefits for more advanced diagnostic tests including imaging techniques (isotopic, PET, CT and MRI scanning, angiography and musculoskeletal ultrasound) and pathologic examination of tissues involved with rheumatic diseases.
CONCA;CC;INC/S;SDL;
CC;RGR;SE
MULTI-SOURCE;ISE
18 Explain
24 Differentiate
MK2Ͳ04
12 Explain major findings and interpretation of more advanced diagnostic tests including
imaging techniques (isotopic, PET, CT and MRI scanning, angiography and musculoskeletal ultrasound) and pathologic examination of tissues involved with rheumatic diseases.
CONCA;CC;INC/S;SDL;
CC;RGR;SE
MULTI-SOURCE; ISE
24 Teach others about
Scholarship (MK3) MK3Ͳ01
6 Demonstrate basic
knowledge of principles underlying critical appraisal of the medical literature. JC;RS MULTI-SOURCE;ISE
24 Demonstrate comprehensive
MK3Ͳ02
6 List
basic biostatistical testing and epidemiological principles.
CC;JC;SDL;QI MULTI-SOURCE;ISE 12 Describe
24 Explain the significance of
24 Implement and interpret
MK3Ͳ03
12 Describe principles underlying research study design for
a scholarly project related to clinical practice, quality improvement, patient safety, medical education or research in collaboration with a faculty mentor.
RS;QI MULTI-SOURCE
18 Generate a hypothesis and select methodology for
24 Perform data collection and analysis for
24 Disseminate findings of
24 Recognize components of grant writing and submission for
MK3Ͳ05
18 Prepare and submit an abstract
to demonstrate effective scientific writing skills.
RS;QI MULTI-SOURCE
24 Prepare and submit a peerͲreviewed manuscript
24 Prepare and submit a nonͲpeer reviewed manuscript for publication (e.g. clinical review, book chapter)
RS;QI MULTI-SOURCE
MK3Ͳ06
12
Effectively present orally at conferences, including but not limited to rheumatology grand rounds, lay education, local and national meetings
to disseminate scholarly work.
RS;QI;JC;RGR;SDL MULTI-SOURCE
18
Present an abstract locally, regionally, or nationally
RS;QI;SDL MULTI-SOURCE
MK3Ͳ07
6 List principles of informed consent as it pertains to investigation, involving human subjects.
RS;CC;JC;SDL MULTI-SOURCE 12 Describe
12 Explain the significance of
12 Enact
PATIENT CARE
Subspecialty Reporting Milestone
Rheumatology Curricular Milestones Your Training Program
Number
By this time
(months)
The fellow should be able to
For this curricular milestone
Activities
Assessment Tools
Gathers and synthesizes essential and accurate information to define each patient’s clinical problem(s). (PC1)
PC1Ͳ01
6 Obtain and report a comprehensive, accurate history, including review of all available records, on patients with rheumatic symptoms and signs.
CONCA;INC/S;SE MULTI-SOURCE;CEX 12 Formulate with relevance
18 Incorporate
18 Teach others the elements of
PC1Ͳ02
12 Perform and report a comprehensive, accurate physical examination, using common and advanced techniques where applicable, on patients with rheumatic symptoms and signs.
CONCA;INC/S;SE;CC MULTI-SOURCE; CEX 18 Distinguish with relevance
18 Integrate
24 Teach others to perform
PC1Ͳ03
6 Order and review diagnostic tests including, but not limited to, laboratory, imaging, electrodiagnostic and pathologic studies for the evaluation of the patient with rheumatic symptoms and signs.
CONCA;INC/S;SE;CC;JC
;SE;
MULTI-
SOURCE;CEX;ISE 12 Interpret
18 Incorporate
24 Teach others about the clinical application of
PC1Ͳ04
6 List the steps of using a standardized approach to the interpretation of musculoskeletal plain radiographs.
CC;SE;CONCA MULTI-SOURCE;ISE 12 Recognize normal anatomy
18 Differentiate abnormal findings
24 Teach others to detect abnormalities
PC1Ͳ05
12 Describe applications, indications and limitations
using a standardized approach for the interpretation of musculoskeletal ultrasonography for diagnostic purposes.
CONCSC;CC;JC;SE MULTI-SOURCE;ISE 24 Recognize normal anatomy
24 Differentiate abnormal findings
PC1Ͳ06 6 Recognize the need to collaboratively review imaging and tissue specimens with radiology and
pathology services, respectively, to enhance patient safety and care INC/S;CONCA;SE MULTI-SOURCE
12 Without faculty member prompting,
Develops and achieves comprehensive management plan for each patient. (PC2)
PC2Ͳ01
6 List the components of a comprehensive treatment plan, based on clinical evidence, clinical context, and patient preferences, counsel patients, and assess response to therapy.
CONCA;INC/S MULTI-SOURCE; CEX 12
For uncomplicated presentations construct and implement
18 For complicated presentations construct and implement
24 Teach others to formulate
PC2Ͳ02
6
Describe state and federal regulations for prescription of controlled substances as part of
a pain management strategy of the care plan.
CC;CONCA;SE;INC/S MULTI-SOURCE; CEX
12
Describe nonͲpharmacologic and pharmacologic components of
12
Implement, and monitor response to therapy, patient compliance, and detect signs and symptoms indicative of analgesic abuse as part of
PC2Ͳ03
6 Describes indications and potential adverse events of
pharmacotherapy, including immunomodulatory agents, used in the management of patients with rheumatic diseases.
CONCA;CC;SE;INC/S MULTI-SOURCE;ISE
12 Obtains verbal or written informed consent for treatment with
18 Prescribe, monitor and assess response to
24 Teaches others to prescribe, monitor and assess response to
PC2Ͳ04
12
In comparison to adults, discuss the similarities and differences in drug disposition and its consequences regarding
pharmacotherapies for use in children and adolescents with rheumatic diseases.
CC;SE;SDL MULTI-SOURCE;ISE
12 List the currently used
24 Prescribe and adjust accordingly
PC2Ͳ05
12 Discuss how the changes in pharmacokinetics that occur with age affect
therapeutic and management strategies in the aging population with rheumatic diseases.
CONCA;CC;SE;INC/S;S
DL
MULTI-SOURCE 18 Prescribe and adjust appropriately
24 Teach others about
PC2Ͳ06
6 List options for exercise and other rehabilitation strategies in the care of patients with rheumatic disorders.
CONCA;CC;SE;SDL MULTI-SOURCE;ISE 12 Describe applications and indications for
18 Incorporate
24 Teach others to incorporate
PC2Ͳ07
6 With attending supervision formulate and implement a management plan for patients with rheumatic emergencies (including organ or life threatening conditions), with a need for
emergent, urgent or changes in level or goals of careǤ
CC;INC/S MULTI-SOURCE 12
With attending supervision for complicated presentations
24 Independently
24 Teach others to
Manages patients with progressive responsibility and independence. (PC3)
PC3Ͳ01
6 Describe the potential manifestations of diseaseͲrelated exacerbations and the influence of comorbid illness during the provision of longitudinal and customized care to patients with rheumatic diseases.
CONCA;CC;SE MULTI-SOURCE 12 Formulate plans to screen for and manage
18 Implement and monitor plans for
24 Teach others to recognize and manage
PC3Ͳ02
6 Identify diseaseͲ and treatmentͲrelated complications that may lead to long term morbidity, including the consideration for implications of comorbid diseases and the effects of aging.
CONCA;CC MULTI-SOURCE;ISE 12
Formulate plans to screen, assess severity, and manage
18 Implement and monitor plans to screen, assess severity, and manage
24 Teach others to recognize and manage
PC3Ͳ03
6 Recognize the psychosocial aspects of rheumatic diseases.
CC;CONCA;SDL MULTI-SOURCE 18 Develop strategies to manage
24 Implement strategies to manage
PC3Ͳ04
6 List and describe the utility of the varied validated instruments in the assessment of pain, disease activity, function, and quality of life over time to monitor and adjust therapy.
CONCA;QI;JC;SE MULTI-SOURCE; ISE 12 Incorporate into practice
18 Teach others to incorporate into practice
Skill in performing procedures. (PC4)
PC4Ͳ01
6 With attending supervision obtain verbal or written informed consent from patient or caregiver for procedures.
CONCA;INC/S;SE MULTI-SOURCE 12 Independently
12 Teach others to
PC4Ͳ02 6 With attending supervision
perform procedures including arthrocentesis and joint and soft tissue injections. CONCA;CC;INC/S MULTI-SOURCE 18 With attending assistance for those that are
complicated or previously unperformed CONCA;INC/S MULTI-SOURCE 24 Independently
24 Teach others to
PC4Ͳ03
24 With attending supervision perform procedures including arthrocentesis and joint and soft tissue injections with ultrasound guidance, when appropriate and feasible.
CONCSC;CONCSU MULTI-SOURCE 24
With attending assistance for those that are complicated or previously unperformed
24 Independently
24 Teach others to
PC4Ͳ04
6 With attending supervision perform compensated polarized microscopy to examine and interpret synovial fluid.
CONCA;CC;INC/S MULTI-SOURCE 12 Independently
18 Teach others to
Requests and provides consultative care. (PC5)
PC5Ͳ01
6 Identify the indications to
refer to other healthcare providers for the coͲmanagement of patients with rheumatic disease.
MULTI-SOURCE 12 Proactively
18 Teach others why, when, and how to
PC5Ͳ02
6 Recognize the tissues commonly considered for
diagnostic biopsies (including, but not limited to, temporal artery, renal, lung, muscle, nerve, skin, minor salivary gland, and brain) in the evaluation of rheumatic diseases, and refers when indicated and appropriate.
CONCA;
INC/S;CC;SE;SDL
MULTI-SOURCE;ISE
12 List the indications, expected risks and benefits, and available alternatives for
18 Implement plans to refer for
18 Teach others how to incorporate
PC5Ͳ03 18 Identify opportunities for referral
to clinical registries and trials. CONCA;RS MULTI-SOURCE 24 Refer when indicated
PC5Ͳ04
6 With attending supervision provide consultation when requested, in support of the primary care relationship, for patients with rheumatic symptoms and signs and appropriately integrate recommendations from other healthcare providers into the evaluation and management plan.
CONCA MULTI-SOURCE
24
Independently
CONCA;INC/S
BASED LEARNING AND IMPROVEMENT PRACTICEͲ
Subspecialty Reporting Milestone
Rheumatology Curricular Milestones
Your Training Program
Number
Activities
Activities
For this curricular milestone
Activities
Assessment Tools
Monitors Practice
with goal for improvement (PBLI1)
PBLI1Ͳ01
6 Acknowledge the importance of reflection to
identify(ied) knowledge or skills gaps to enhance future clinical interactions.
CONCA;SE;SDL MULTI-SOURCE; ISE 12 Routinely reflect on clinical interactions to
12 Describe his or her own efforts to
18 Seek resources to address
PBLI1Ͳ02 18 Recognize ways to improve his/her role in the effective management of a practice. CONCA;SE MULTI-SOURCE
24 Implement
Learns and improves via performance audit. (PBLI2)
PBLI2Ͳ
01
6 Can describe what s/he learns from errors.
CONCA;INC/S;SE;SDL;R
GR
MULTI-SOURCE;CEX 18
Independently identify and describe what s/he
24
Demonstrate through actions taken to improve the system or processes of care that s/he
PBLI2Ͳ
02
18 Identify an area of inquiry to direct an audit of a panel of patients using standardized, diseaseͲspecific, and evidenceͲbased criteria.
QI;RS MULTI-SOURCE 24 Design the method for
24 Perform and analyze
24
Reflect on and hypothesize an explanation for deficiencies found (including doctorͲ related, systemͲrelated, and patientͲ related factors) through
QI;RS;SDL MULTI-SOURCE
24 Change practice based on results of
Learns and improves
via feedback. (PBLI3)
PBLI3Ͳ 01
12 Accept and reflect on
feedback from all members of the health care team including faculty, peers, students, nurses, allied health workers, patients and their advocates.
CONCA;SE;SDL MULTI-SOURCE
12 Actively seek and reflect on
12 Develop plans for practice improvement based on
Learns and improves
at the point of care. (PBLI4)
PBLI4Ͳ
01
6 Identify basic knowledge gaps and seek answers to clinical questions, and performs selfͲreflection to incorporate learning for future clinical encounters.
CONCA;SE;SDL MULTI-SOURCE;CEX 12
In all cases, independently construct and pursue
PBLI4Ͳ
02
6 Independently use(s) technology to manage information (HIPAA compliant), support patient care decisions using evidenceͲbased medicine and enhance both patient and physician education.
SDL;CONCA;SE;INC/S MULTI-SOURCE 12 Teach others to
PBLI4Ͳ 03
6 With prompting from faculty maintains awareness of the situation in the moment, and responds to meet situational needs.
CONCA;INC/S;SE; MULTI-SOURCE 12 Independently
PBLI4Ͳ
04 12 Determines applicability of
clinical evidence for individualized patient care. CONCA;INC/S;SE MULTI-SOURCE;CEX 12 Customizes management based on
SYSTEMS BASED PRACTICE
Subspecialty Reporting Milestone
Rheumatology Curricular Milestones
Your Training Program
Number
By this time
(months)
The fellow should be able to
For this curricular milestone
Activities
Assessment Tools
Works effectively within an interprofessional team (e.g. peers, consultants, nursing, therapists, nurses, home care workers, pharmacists, social workers and other ancillary professionals and other support personnel). (SBP1)
SBP1Ͳ01 6 Acknowledge the contributions from
health care providers from varied disciplines to promote patientͲcentered care. CONCA;SE;INC/S MULTI-SOURCE;CEX 12 Actively participate and work with
SBP1Ͳ02
6 Recognize the varied health care providers who work to promote patient safety and to identify risks for and strategies to prevent medical errors.
CONCA;SE;INC/S;QI MULTI-SOURCE 12 Explain the contributions of
24 Participate in the activities of
SBP1Ͳ03
6 List the individual components that contribute to
appropriate coding based on documentation and reimbursement policies.
CONCA;SE MULTI-SOURCE
18 Ascribe levels of complexity to the components that comprise
24 Implement
SBP1Ͳ04
6 Describes the spectrum of practice models for health care delivery, including the fundamentals of office and personnel management.
CONCA;SE MULTI-SOURCE 18 Differentiates among
24 Works effectively within
Recognizes system error and advocates for system improvement. (SPB2)
SBP2Ͳ01
6
Recognize situations leading to inefficiencies, safety concerns and/or preventable medical errors when
partnering with other healthcare teams and professionals to improve the quality of care and patient safety within the system.
CONCA;SE;QI;INC/S MULTI-SOURCE;CEX
12 Participate in a system level quality improvement initiatives while
24 Design and implement a system level quality improvement initiative while
SBP2Ͳ02 12 Demonstrate ability to recognize opportunities to address causes of disparity in disease and healthcare
delivery. CONCSC;INC/S MULTI-SOURCE
24 Assist others within one’s own system to
24 Assist the public to Identifies factors that impact the cost of health care, and advocates for, and practices costͲeffective care. (SBP3)
SBP3Ͳ01
6 Recognize the necessity to integrate cost awareness and cost benefit analysis for disease specific care as well as in individual patients.
CONCSU;SE;CC;SDL;RS MULTI-SOURCE 18 Participate in decisions that reflect
24 Independently incorporate considerations of
SBP3Ͳ02
6 Recognize barriers impacting patient care, including socioͲeconomic factors, healthcare literacy, medical disability and health care insurance coverage.
CONCA;SE;CC;SDL MULTI-SOURCE 18 Identify ways to address
18 Advocate for change of
24 Implement measures to correct
SBP3Ͳ03
6 Identify
the various health care settings (academic/public/private/VA) and stakeholders in the healthcare economy.
CONCA;SE;SDL;CC;INC/
S
MULTI-SOURCE
18 Describe the impact on health care cost and access by
24 Leverage the advantages, for individual patients, of
Transitions patients effectively within and across health delivery systems. (SBP4)
SBP4Ͳ01
6 Identify the providers, therapies, and potential obstacles to successfully
coordinate care across multiple delivery systems, including ambulatory, subacute, acute, rehabilitation and skilled nursing facilities.
INC/SE MULTI-SOURCE;HAE
18 Discuss strategies to overcome the obstacles to successfully
24 Implement strategies to successfully
INTERPERSONAL AND COMMUNICATION SKILLS
Subspecialty Reporting Milestone
Rheumatology Curricular Milestones
Your Training Program
Number
By this time
(months)
The fellow should be able to
For this curricular milestone
Activities
Assessment Tools
Communicates effectively with patients and caregivers. (ICS1)
ICS1Ͳ01
6 Use nonverbal skills, and without interruption
listen carefully to patients and caregivers to create rapport and build a therapeutic relationship.
CONCA;INC/S MULTI-SOURCE; CEX 6 Ask thoughtful questions based on ability to
ICS1Ͳ02
6 Use plain language, avoiding technical medical terms, to
explain and counsel patients and caregivers about their problems, proposed examinations and treatments, and findings.
CONCA;INC/S;SE MULTI-SOURCE;CEX 6 Appropriately use an interpreter to
12 Encourage questions, answering clearly, incorporating new insights to
ICS1Ͳ03
6 Recognize the need to incorporate patient preferences to
share decisionͲmaking in both diagnostic and therapeutic scenarios.
CONCA;INC/S;SE;CC MULTI-SOURCE;CEX 12 Incorporate patient preferences to
18 Solicit and incorporate patient preferences surrounding uncomplicated situations to
24
Solicit and incorporate patient preferences surrounding ambiguous or controversial situations to
ICS1Ͳ04
6 Demonstrate sensitivity to differences in patients including, but not limited to race, culture, gender, sexual orientation, socioeconomic status, literacy, religious beliefs.
CONCA;INC/S;SE;CC MULTI-
SOURCE;CEX;SDL 12 Actively seek to understand
18 Integrate into evaluation and management plans
Communicates effectively in interprofessional teams
ICS2Ͳ01
6 Describe the importance of communication with other healthcare providers in order to maintain appropriate continuity during transitions of care, including from pediatric to adult rheumatology care.
INC/S;SE;CC MULTI-SOURCE;CEX 12 Proactively initiate
(e.g., with peers, consultants, nursing, ancillary professionals, and other support personnel). (ICS2)
ICS2Ͳ02
6 Recognize the roles and acknowledge the contributions of individuals in support of
productive interaction within interprofessional teams.
INC/S;CONCA;QI;RS MULTI-SOURCE;HAE
12 Interact, adapting and shifting roles as necessary, in support of
18 Initiate problem solving for
18 Assume a leadership role in the education of all members in support of
ICS2Ͳ03
6 Utilize common technologies for
effective presentation for the specific audience.
RGR;JC;RS MULTI-SOURCE
18 Tailor topic selection, presentation technology, and verbal and nonverbal skills for
24
Role model proficiency in tailored topic selection, presentation technology, and verbal and nonverbal skills for
Appropriate utilization and completion of health records. (ICS3)
ICS3Ͳ01
6 Document through templates/scripts to create
timely and legible authentic documentation that includes a differential diagnosis and clinical reasoning, and support for the appropriate level of reimbursement.
CONCA;SE;INC/S;RGR MULTI-SOURCE;CEX
12 Adjust communication on the basis of context, audience and/or situation for relevant and succinct,
18 Organize complex cases into relevant and succinct,
PROFESSIONALISM
Subspecialty Reporting Milestone
Rheumatology Curricular Milestones
Your Training Program
Number
Activities
Activities
For this curricular milestone
Activities
Assessment Tools
Has professional and respectful interactions with patients, caregivers, and members of the interprofessional team (e.g., peers, consultants, nursing, ancillary professionals, and support personnel). (PROF1)
PROF1Ͳ
01
12 Recognize and manage differences of opinion with patients to
demonstrate respectful professional interactions.
INC/S;CONCA;QI;RGR;
SE
MULTI-SOURCE
12 Recognize and manage differences of opinion with other members of the interprofessional team to
12 Provide constructive feedback to other members of the health care team to
PROF1Ͳ 02
6 Provide responsible team leadership to demonstrate respect for patient dignity and autonomy. INC/S;CONCA;SE MULTI-SOURCE;CEX
PROF1Ͳ
03
6
Recognize, respond to, and report impairment in colleagues or substandard care via peer review process
as a demonstration of commitment to providing safe patient care.
QI;CONCA MULTI-SOURCE
Accepts responsibility and follows through on tasks. (PROF2)
PROF2Ͳ 01
6
Recognize the scope of his/her abilities and ask for supervision and assistance appropriately
as demonstration of personal accountability.
CONCA;SE MULTI-SOURCE
6
When indicated, identify and assist colleagues in need of assistance in the provision of duties
12
Through his/her actions, serve as a professional role model for peers and learners
24
Contribute to the fiscally sound practice of an office
1 Demonstrates appropriate professional appearance
CONCA;INC/S;SE;RGR MULTI-SOURCE;CEX
PROF2Ͳ
02
6
Respond promptly and appropriately to clinical responsibilities including but not limited to calls and pages
as a demonstration of the professional attribute of accessibility.
CONCA;INC/S;SE;RS;QI MULTI-SOURCE
6
Carry out timely interactions with colleagues, patients, and their designated caregivers
12
Ensure prompt completion of clinical, administrative, curricular and researchͲ related tasks
Responds to each patient’s unique characteristics and needs. (PROF3)
PROF3Ͳ
01
6 Represent individual patient needs
as a demonstration of being an advocate for all patients.
CONCA;INC/S;SE MULTI-SOURCE;CEX Show empathy and compassion to all
patients
12 Address disparities in health care among populations that may impact patient care
6
Take responsibility for situations where public health supersedes individual privacy (e.g. reportable infectious diseases)
PROF3Ͳ 02
6
Treat patients with dignity, civility and respect, regardless of race, culture, gender, sexual orientation, socioeconomic status, literacy, and religious beliefs
as a demonstration of showing compassion and respect to patients.
CONCA;INC/S;SE MULTI-SOURCE;CEX
6
Make efforts to support (physical, psychological, social, and spiritual) patients with acute and chronic, basic and complex rheumatic diseases and their caregivers.
Exhibits integrity and ethical behavior in professional conduct. (PROF4)
PROF4Ͳ 01
6 Document and report clinical and research information truthfully
as a demonstration of adhering to basic ethical principles.
CONCA;SE;INC/S;QI;RS MULTI-SOURCE 6 Follow formal policies
6 Accept personal errors and honestly acknowledge them
6
Maintain patient confidentiality
6
Uphold ethical expectations of clinical, scholarly activity and research including maintenance of upͲtoͲdate certifications for all professional activities
PROF4Ͳ 02
6
Maintain and monitor patient care relationships with colleagues, members of the interprofessional team and office staff to
manage conflicts of interest.
CONCA;SE;RS MULTI-SOURCE
6 Use technology and social media appropriately to
6 Maintain ethical relationships with industry to
6
Addresses personal, psychological, and physical limitations that may affect professional performance to
1
Rheumatology Fellowship
ACGME Competency-based Curriculum: Goals and Objectives Subspecialty Clinic Rotations
* ACGME Competency Goals, defined:PC – Provide patient care that is compassionate, appropriate, and effective for the treatment of health problems.MK – Demonstrate knowledge of evolving science and apply the knowledge to patient careICS – (a) Communicate effectively with physicians, other health professionals and health related agencies; (b) Work effectively as a member or leader of a healthcare teamP – Demonstrate commitment to carrying out professional responsibilities and adherence to ethical principles.PLI – Evaluate your care of patients, appraise scientific evidence, and improve care through self-evaluation and life-long learning.SBP - Be aware and responsive to the larger context of health care. Call effectively on the resources in the system to provide optimal care.
NOTE: Except where indicated by *, goals and objective are the same for PGY 4 and PGY 5. Goals/objectives preceded by * indicate those specific to PGY 5 trainees
5
ROTATION: Rheumatoid Arthritis and Psoriatic Arthritis Clinic Rotation Year: PGY 4 and 5
Goal 1. To enable rheumatology trainees to enhance their knowledge of the epidemiology, pathophysiology, clinical features, diagnosis, and management of Rheumatoid Arthritis (RA) and Psoriatic Arthritis (PsA). Fellow Objectives Instructional Strategies Assessment of Competence ACGME Competency Goals *
1. Demonstrates knowledge ofindications, contraindications,limitations, and interpretation ofresults of diagnostic and therapeuticprocedures specific to RA and PsA.
Direct RA/PsA patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
MK, PC
2. Demonstrates competency in thediagnosis and management of bothacute processes (disease flares,infections) and chronic diseasemanifestations (including subsets ofarticular manifestations of PsA, extra- articular manifestations of RA).
Direct RA/PsA patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
PC, MK
3. Demonstrates knowledge ofscreening for and treatment of long- term complications of RA, includingcardiovascular disease andosteoporosis.
Direct RA patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
MK, PC
4. Demonstrates knowledge of theevolving armamentarium ofmedications used to treat RA and PsA,including potential side effects andmonitoring strategies for use ofDMARDs and biologics; * demonstrateability to synthesize and interpret themedical literature to make evidence- based decisions in the treatment ofpatients; demonstrate understandingof treat-to-target strategies in RA.
Direct RA/PsA patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
MK, PC, PLI
5. Demonstrates knowledge ofradiographic features of articulardisease in RA and PsA.
Direct RA/PsA patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
MK
Goal 2. To allow trainees to enhance their knowledge of best-practice guidelines and quality indicators for the management of patients with RA and SLE, and to learn to incorporate these metrics into clinical care.
6
Fellow Objectives Instructional Strategies Assessment of Competence ACGME Competency Goals *
1. Demonstrates familiarity with best- practice guidelines and quality indicators for the management of patients with RA, including screening for disease-related and treatment- related complications that lead to long-term morbidity (osteoporosis, cardiovascular disease, viral infections).
Direct RA patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
SBP, PC, MK, PLI
2. Demonstrates an understanding of current guidelines for the management of RA (particularly an understanding of strategies for escalation of therapy, treat-to-target goals, and *the routine use and documentation of outcome metrics such as CDAI and RAPID3).
Direct RA patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Attending review of fellow documentation Self-reflection assessment tool
PLI, SBP, PC
Goal 3. To familiarize trainees with the important systems-based practice issues at play in the care of patients with a chronic, serious illness such as RA or PsA. Fellow Objectives Instructional Strategies Assessment of Competence ACGME Competency Goals *
1. Develops an appreciation of the importance of coordinating care among multiple health professionals (nurses, physical therapists, social workers, counselors, psychologists, other physicians).
Direct RA/PsA patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
SBP, ICS, P
2. Demonstrates an appreciation of the importance of advocating for quality care for patients (pre-authorizations for medications, filing disability claims, etc).
Direct RA/PsA patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
SBP, ICS, P
3. * Develops an understanding of evidence-based cost-conscious patient care.
Direct RA/PsA patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
SBP, ICS, P
Goal 4. To enable trainees to cultivate an appreciation of research ethics. Fellow Objectives Instructional Strategies Assessment of Competence ACGME Competency Goals *
1. * Demonstrates an understanding of the patient consent process and the complexities for both patients and
Direct RA/PsA patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
P, PC
7
investigators of designing and implementing clinical outcome studies of therapeutic agents.
Goal 5. To enable trainees to enhance their interpersonal and communication skills. Fellow Objectives Instructional Strategies Assessment of Competence ACGME Competency Goals *
1. Develops an appreciation of the myriad challenges faced by patients with a serious chronic illness such as RA or PsA, with a particular focus on the social, emotional, and economic burden of chronic disease.
Direct RA/PsA patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
ICS, P
2. Demonstrates ability to work effectively with colleagues and peers (including nurses, physical therapists, social workers, counselors, psychologists and other physicians) to coordinate the care of complex patients with RA and PsA.
Direct RA/PsA patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
ICS, P
8
ROTATION: Vasculitis Clinic Rotation Year: PGY 4 and 5
Goal 1. To enable rheumatology trainees to enhance their knowledge of the epidemiology, pathophysiology, clinical features, diagnosis, and management of Vasculitides.
Fellow Objectives Instructional Strategies Assessment of Competence ACGME Competency Goals *
1. Demonstrates competency in the diagnosis of both acute processes (disease flares, infections) and chronic disease manifestations (including understanding clinical features, laboratory findings, characteristics, and biopsy findings of small, medium, and large-vessel vasculitides).
Direct vasculitis patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
MK, PC
2. Demonstrates knowledge of indications, contraindications, limitations, and interpretation of results of diagnostic procedures specific to vasculitides (e.g., imaging tests, biopsies).
Direct vasculitis patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
MK, PC
3. Demonstrates knowledge of the evolving armamentarium of medications used to treat vasculitides, including potential side effects and monitoring strategies for use of these medications;* demonstrates ability to synthesize and interpret the medical literature to make evidence-based decisions in the treatment of patients.
Direct vasculitis patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
MK, PC, PLI
Goal 2. To allow trainees to enhance their knowledge of best-practice guidelines and quality indicators for the management of patients with vasculitis, and to learn to incorporate these metrics into clinical care. Fellow Objectives Instructional Strategies Assessment of Competence ACGME Competency Goals *
1. Demonstrates familiarity with best- practice guidelines and quality indicators for the management of patients with vasculitis, including screening for disease-related and treatment-related complications that
Direct vasculitis patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
SBP, PC, MK, PLI
9
lead to long-term morbidity (particularly potential toxicities of Cyclophosphamide and Rituximab).
Goal 3. To familiarize trainees with the important systems-based practice issues at play in the care of patients with a chronic, serious illness such as RA or PsA. Fellow Objectives Instructional Strategies Assessment of Competence ACGME Competency Goals *
1. Develops an appreciation of the importance of coordinating care among multiple health professionals (nurses, physical therapists, social workers, counselors, psychologists, other physicians).
Direct vasculitis patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
SBP, ICS, P
2. Demonstrates an appreciation of the importance of advocating for quality care for patients (pre-authorizations for medications, filing disability claims, etc).
Direct vasculitis patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
SBP, ICS, P
3. * Develops an understanding of evidence-based cost-conscious patient care.
Direct vasculitis patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
SBP, ICS, P
Goal 4. To enable trainees to enhance their interpersonal and communication skills. Fellow Objectives Instructional Strategies Assessment of Competence ACGME Competency Goals *
1. Develops an appreciation of the myriad challenges faced by patients with a serious chronic illness such as vasculitis, with a particular focus on the social, emotional, and economic burden of chronic disease.
Direct vasculitis patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
ICS, P
2. Demonstrates ability to work effectively with colleagues and peers (including nurses, physical therapists, social workers, counselors, psychologists and other physicians) to coordinate the care of complex patients with vasculitis.
Direct vasculitis patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
ICS, P
10
ROTATION: Crystalline Arthropathy Clinic Rotation Year: PGY 4 and 5
Goal 1. To enable rheumatology trainees to enhance their knowledge of the epidemiology, pathophysiology, clinical features, diagnosis, and management of crystalline arthropathies.
Fellow Objectives Instructional Strategies Assessment of Competence ACGME Competency Goals *
1. Demonstrates knowledge of indications, contraindications, limitations, and interpretation of results of diagnostic and therapeutic procedures specific to gout and CPPD.
Direct gout/CPPD patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
MK, PC
2. Demonstrates competency in the diagnosis and management of both acute processes (disease flares, infections) and chronic disease manifestations (including chronic tophaceous gout).
Direct gout/CPPD patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
PC, MK
3. Demonstrates competency in the synovial crystal analysis using polarized microscopy.
Direct gout/CPPD patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
MK, PC
4. Demonstrates knowledge of the evolving armamentarium of medications used to treat gout and CPPD, including potential side effects and monitoring strategies for use of these medications and treatment goals.
Direct gout/CPPD patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
MK, PC, PLI
5. Demonstrates knowledge of radiographic features of gout and CPPD.
Direct gout/CPPD patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
MK
Goal 2. To familiarize trainees with the important systems-based practice issues at play in the care of patients with a chronic, serious illness such as gout or CPPD. Fellow Objectives Instructional Strategies Assessment of Competence ACGME Competency Goals *
1. Develops an appreciation of the importance of coordinating care among multiple health professionals (nurses, physical therapists, social workers, counselors, psychologists,
Direct gout/CPPD patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
SBP, ICS, P
11
other physicians). 2. Demonstrates an appreciation of the
importance of advocating for quality care for patients (pre-authorizations for medications, filing disability claims, etc).
Direct gout/CPPD patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
SBP, ICS, P
3. * Develops an understanding of evidence-based cost-conscious patient care.
Direct gout/CPPD patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
SBP, ICS, P
Goal 3. To enable trainees to enhance their interpersonal and communication skills. Fellow Objectives Instructional Strategies Assessment of Competence ACGME Competency Goals *
1. Develops an appreciation of the myriad challenges faced by patients with a chronically painful and potentially disfiguring disease such as gout or CPPD, with a particular focus on the social, emotional, and economic burden of chronic disease.
Direct gout/CPPD patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
ICS, P
2. Demonstrates ability to work effectively with colleagues and peers (including nurses, physical therapists, social workers, counselors, psychologists and other physicians) to coordinate the care of patients with gout and CPPD.
Direct gout/CPPD patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
ICS, P
12
ROTATION: Combined Rheumatology-Dermatology Clinic Rotation Year: PGY 4 and 5
Goal 1. To enable rheumatology trainees to enhance their knowledge of the epidemiology, pathophysiology, clinical features, diagnosis, and management of autoimmune dermatologic disease and idiopathic inflammatory myopathies (IIM).
Fellow Objectives Instructional Strategies Assessment of Competence ACGME Competency Goals *
1. Demonstrate competency in the identification and classification of dermatologic manifestations of autoimmune disease.
Direct patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
MK, PC
2. Demonstrates knowledge of indications, contraindications, limitations, and* interpretation of skin biopsies in evaluating dermatologic manifestations of autoimmune disease.
Direct patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
MK, PC
3. Demonstrate knowledge of the presentation, differential diagnosis, and evaluation (including the role of imaging studies and tissue diagnosis) of IIM and potential concurrent diagnoses (particularly malignancies).
Direct patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
MK, PC
4. Demonstrate knowledge of the evolving armamentarium of medications used to treat IIM, including potential side effects and monitoring strategies for use of these medications; * demonstrate ability to synthesize and interpret the medical literature to make evidence-based decisions in the treatment of patients.
Direct patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
MK, PC, PLI
Goal 2. To allow trainees to enhance their knowledge of best-practice guidelines and quality indicators for the management of patients with dermatologic manifestations of autoimmune disease, and to learn to incorporate these metrics into clinical care. Fellow Objectives Instructional Strategies Assessment of Competence ACGME Competency Goals *
1. Demonstrate familiarity with best- practice guidelines and quality indicators for the management of patients with IIM, including screening
Direct patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
SBP, PC, MK, PLI
13
for disease-related and treatment- related complications that lead to long-term morbidity (particularly potential toxicities of medications, importance of evaluation for concurrent malignancies).
Goal 3. To familiarize trainees with the important systems-based practice issues at play in the care of patients with a chronic, serious illness such as IIM or autoimmune dermatologic disease. Fellow Objectives Instructional Strategies Assessment of Competence ACGME Competency Goals *
1. Develop an appreciation of the importance of coordinating care among multiple health professionals (nurses, physical therapists, social workers, counselors, psychologists, other physicians).
Direct patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
SBP, ICS, P
2. Demonstrate an appreciation of the importance of advocating for quality care for patients (pre-authorizations for medications, filing disability claims, etc).
Direct patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
SBP, ICS, P
3. * Develop an understanding of evidence-based cost-conscious patient care.
Direct patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
SBP, ICS, P
Goal 4. To enable trainees to enhance their interpersonal and communication skills. Fellow Objectives Instructional Strategies Assessment of Competence ACGME Competency Goals *
1. Develop an appreciation of the myriad challenges faced by patients with a serious chronic illness such as IIM, with a particular focus on the social, emotional, and economic burden of chronic disease.
Direct patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
ICS, P
2. Develop an appreciation of the challenges faced by patients with potentially disfiguring diseases, such as dermatologic autoimmune disease, with a particular focus on the social, emotional, and economic burden of chronic disease.
Direct patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
ICS, P
14
3. Demonstrate ability to work
effectively with colleagues and peers
(including nurses, physical therapists,
social workers, counselors,
psychologists and other physicians) to
coordinate the care of complex
patients.
Direct vasculitis patient care
Self-directed learning
Global MedHub rating form by attending
Self-reflection assessment tool
ICS, P
1
Rheumatology Fellowship
ACGME Competency-based Curriculum: Goals and Objectives Subspecialty Clinic Rotations
* ACGME Competency Goals, defined: PC – Provide patient care that is compassionate, appropriate, and effective for the treatment of health problems. MK – Demonstrate knowledge of evolving science and apply the knowledge to patient care ICS – (a) Communicate effectively with physicians, other health professionals and health related agencies; (b) Work effectively as a member or leader of a health care team P – Demonstrate commitment to carrying out professional responsibilities and adherence to ethical principles. PLI – Evaluate your care of patients, appraise scientific evidence, and improve care through self-evaluation and life-long learning. SBP - Be aware and responsive to the larger context of health care. Call effectively on the resources in the system to provide optimal care. NOTE: Except where indicated by *, goals and objectives are the same for PGY 4 and PGY 5 Goals/objectives preceded by * are specific for PGY 5 level trainees
ROTATION: Stanford Continuity Clinic Year: PGY 4, PGY 5
Goal 1. To enable rheumatology trainees to enhance their knowledge of the epidemiology, pathophysiology, clinical features, diagnosis, and management of a broad array of autoimmune and rheumatologic conditions.
Fellow Objectives Instructional Strategies Assessment of Competence ACGME Competency Goals *
1. Demonstrates knowledge of indications, limitations, and interpretation of laboratory tests (particularly autoantibodies) in the diagnosis of systemic autoimmune disease.
Direct patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
MK, PC
2. Demonstrates knowledge of the differential diagnosis and appropriate management of monoarticular arthritis.
Direct patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
MK, PC
3. Demonstrates knowledge of the differential diagnosis and appropriate management of polyarticular arthritis.
Direct patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
MK, PC
2
4. Demonstrates competence in the care of patients with the most commonly encountered rheumatic diseases, including: RA, SLE, Sjogren’s
Direct patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
PC, MK
3
syndrome, myositis, systemic sclerosis, vasculitides, seronegative spondylarthritidies, infectious arthritides, crystal-associated diseases.
5. Demonstrates competence in the care of patients with bone and cartilage disorders, including: osteoarthritis, metabolic bone disease.
Direct patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
PC, MK
6. Demonstrates competence in the identification of patients with nonarticular and regional musculoskeletal disorders, including: fibromyalgia, regional musculoskeletal disorders (e.g. bursitis), overuse rheumatic syndromes.
Direct patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
PC, MK
7. * Demonstrates interest in and willingness to review literature to guide management of rare rheumatic diseases; bone and cartilage disorders; hereditary, congenital, and inborn errors of metabolism associated with rheumatic syndromes; nonarticular and regional musculoskeletal disorders; neoplasms and tumor-like lesions; and muscle diseases.
Direct patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
PC, MK, PLI
Goal 2. To allow trainees to enhance their knowledge of best-practice guidelines and quality indicators for the management of patients with rheumatologic conditions, and to learn to incorporate these metrics into clinical care. Fellow Objectives Instructional Strategies Assessment of Competence ACGME Competency Goals *
1. Demonstrates familiarity with commonly used medications in the treatment of rheumatologic conditions, potential adverse effects of these medications, and appropriate monitoring strategies.
Direct patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
PC, MK
2. Demonstrates awareness of common co-morbidities among patients with
Direct patient care Self-directed learning
Global MedHub rating form by attending Attending review of fellow documentation
SBP, PC
4
systemic autoimmune disease— including increased risk of cardiovascular disease, osteoporosis, and increased risk of infection—and appropriate preventive management strategies
Review of trainee documentation Self-reflection assessment tool
3. Demonstrates familiarity with indications for and methods of rehabilitation for common musculoskeletal conditions and an appreciation of the importance of a multi-disciplinary approach to treating these conditions.
Direct patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
SBP, PC
Goal 3. To familiarize trainees with the important systems-based practice issues at play in the care of patients with chronic, serious illness. Fellow Objectives Instructional Strategies Assessment of Competence ACGME Competency Goals *
1. Develops an appreciation of the importance of coordinating care among multiple health professionals (nurses, physical therapists, social workers, counselors, psychologists, other physicians).
Direct patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
SBP, ICS, P
2. Demonstrates an appreciation of the importance of advocating for quality care for patients (pre-authorizations for medications, filing disability claims, etc).
Direct patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
SBP, ICS, P
3. * Develops an understanding of evidence-based cost-conscious patient care.
Direct patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
SBP, ICS, P
Goal 4. To enable trainees to enhance their interpersonal and communication skills. Fellow Objectives Instructional Strategies Assessment of Competence ACGME Competency Goals *
1. Develops an appreciation of the myriad challenges faced by patients with serious chronic illnesses, with a particular focus on the social, emotional, and economic burden of chronic disease.
Direct patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
ICS, P
2. Demonstrate ability to work Direct patient care Global MedHub rating form by attending ICS, P
5
effectively with colleagues and peers (including nurses, physical therapists, social workers, counselors, psychologists and other physicians) to coordinate the care of complex patients.
Self-directed learning Self-reflection assessment tool
ROTATION: VA Clinic Year: PGY 4, PGY 5
Goal 1. To enable rheumatology trainees to enhance their knowledge of the epidemiology, pathophysiology, clinical features, diagnosis, and management of a broad array of autoimmune and rheumatologic conditions.
Fellow Objectives Instructional Strategies Assessment of Competence ACGME Competency Goals *
1. Demonstrates knowledge of indications, limitations, and interpretation of laboratory tests (particularly autoantibodies) in the diagnosis of systemic autoimmune disease.
Direct patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
MK, PC
2. Demonstrates knowledge of the differential diagnosis and appropriate management of monoarticular arthritis.
Direct patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
MK, PC
3. Demonstrates knowledge of the differential diagnosis and appropriate management of polyarticular arthritis.
Direct patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
MK, PC
4. Demonstrate competence in the care of patients with the most commonly encountered rheumatic diseases, including: RA, SLE, Sjogren’s syndrome, myositis, systemic sclerosis, vasculitides, seronegative spondylarthritidies, infectious arthritides, crystal-associated diseases.
Direct patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
PC, MK
5. Demonstrates competence in the care of patients with bone and cartilage disorders, including: osteoarthritis,
Direct patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
PC, MK
6
metabolic bone disease. 6. Demonstrates competence in the
identification of patients with nonarticular and regional musculoskeletal disorders, including: fibromyalgia, regional musculoskeletal disorders (e.g. bursitis), overuse rheumatic syndromes.
Direct patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
PC, MK
7. * Demonstrates interest in and willingness to review literature to guide management of rare rheumatic diseases; bone and cartilage disorders; hereditary, congenital, and inborn errors of metabolism associated with rheumatic syndromes; nonarticular and regional musculoskeletal disorders; neoplasms and tumor-like lesions; and muscle diseases.
Direct patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
PC, MK, PLI
Goal 2. To allow trainees to enhance their knowledge of best-practice guidelines and quality indicators for the management of patients with rheumatologic conditions, and to learn to incorporate these metrics into clinical care. Fellow Objectives Instructional Strategies Assessment of Competence ACGME Competency Goals *
1. Demonstrates familiarity with commonly used medications in the treatment of rheumatologic conditions, potential adverse effects of these medications, and appropriate monitoring strategies.
Direct patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
PC, MK
2. Demonstrates awareness of common co-morbidities among patients with systemic autoimmune disease— including increased risk of cardiovascular disease, osteoporosis, and increased risk of infection—and appropriate preventive management strategies.
Direct patient care Self-directed learning Review of trainee documentation
Global MedHub rating form by attending Attending review of fellow documentation Self-reflection assessment tool
SBP, PC
3. Demonstrates familiarity with indications for and methods of
Direct patient care Didactic lectures
Global MedHub rating form by attending Self-reflection assessment tool
SBP, PC
7
rehabilitation for common musculoskeletal conditions and an appreciation of the importance of a multi-disciplinary approach to treating these conditions.
Self-directed learning
Goal 3. To familiarize trainees with the important systems-based practice issues at play in the care of patients with chronic, serious illness. Fellow Objectives Instructional Strategies Assessment of Competence ACGME Competency Goals *
1. Develops an appreciation of the importance of coordinating care among multiple health professionals (nurses, physical therapists, social workers, counselors, psychologists, other physicians).
Direct patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
SBP, ICS, P
2. Demonstrates an appreciation of the importance of advocating for quality care for patients (pre-authorizations for medications, filing disability claims, etc).
Direct patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
SBP, ICS, P
3. * Develops an understanding of evidence-based cost-conscious patient care.
Direct patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
SBP, ICS, P
Goal 4. To enable trainees to enhance their interpersonal and communication skills. Fellow Objectives Instructional Strategies Assessment of Competence ACGME Competency Goals *
1. Develops an appreciation of the myriad challenges faced by patients with serious chronic illnesses, with a particular focus on the social, emotional, and economic burden of chronic disease.
Direct patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
ICS, P
2. Demonstrates ability to work effectively with colleagues and peers (including nurses, physical therapists, social workers, counselors, psychologists and other physicians) to coordinate the care of complex patients.
Direct patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
ICS, P
8
ROTATION: Santa Clara Valley Medical Clinic Year: PGY 4, PGY 5
Goal 1. To enable rheumatology trainees to enhance their knowledge of the epidemiology, pathophysiology, clinical features, diagnosis, and management of a broad array of autoimmune and rheumatologic conditions.
Fellow Objectives Instructional Strategies Assessment of Competence ACGME Competency Goals *
1. Demonstrates knowledge of indications, limitations, and interpretation of laboratory tests (particularly autoantibodies) in the diagnosis of systemic autoimmune disease.
Direct patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
MK, PC
2. Demonstrates knowledge of the differential diagnosis and appropriate management of monoarticular arthritis.
Direct patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
MK, PC
3. Demonstrates knowledge of the differential diagnosis and appropriate management of polyarticular arthritis.
Direct patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
MK, PC
4. Demonstrates competence in the care of patients with the most commonly encountered rheumatic diseases, including: RA, SLE, Sjogren’s syndrome, myositis, systemic sclerosis, vasculitides, seronegative spondylarthritidies, infectious arthritides, crystal-associated diseases.
Direct patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
PC, MK
5. Demonstrates competence in the care of patients with bone and cartilage disorders, including: osteoarthritis, metabolic bone disease.
Direct patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
PC, MK
6. Demonstrates competence in the identification of patients with nonarticular and regional musculoskeletal disorders, including: fibromyalgia, regional musculoskeletal disorders (e.g. bursitis), overuse
Direct patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
PC, MK
9
rheumatic syndromes. 7. * Demonstrates interest in and
willingness to review literature to guide management of rare rheumatic diseases; bone and cartilage disorders; hereditary, congenital, and inborn errors of metabolism associated with rheumatic syndromes; nonarticular and regional musculoskeletal disorders; neoplasms and tumor-like lesions; and muscle diseases.
Direct patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
PC, MK, PLI
Goal 2. To allow trainees to enhance their knowledge of best-practice guidelines and quality indicators for the management of patients with rheumatologic conditions, and to learn to incorporate these metrics into clinical care. Fellow Objectives Instructional Strategies Assessment of Competence ACGME Competency Goals *
1. Demonstrates familiarity with commonly used medications in the treatment of rheumatologic conditions, potential adverse effects of these medications, and appropriate monitoring strategies.
Direct patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
PC, MK
2. Demonstrates awareness of common co-morbidities among patients with systemic autoimmune disease— including increased risk of cardiovascular disease, osteoporosis, and increased risk of infection—and appropriate preventive management strategies.
Direct patient care Self-directed learning Review of trainee documentation
Global MedHub rating form by attending Attending review of fellow documentation Self-reflection assessment tool
SBP, PC
3. Demonstrates familiarity with indications for and methods of rehabilitation for common musculoskeletal conditions and an appreciation of the importance of a multi-disciplinary approach to treating these conditions.
Direct patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
SBP, PC
Goal 3. To familiarize trainees with the important systems-based practice issues at play in the care of patients with chronic, serious illness. Fellow Objectives Instructional Strategies Assessment of Competence ACGME Competency Goals *
10
1. Demonstrates culture competency in treating patients from diverse backgrounds and familiarity with the use of interpreters in caring for patients who are not comfortable communicating primarily in English.
Direct patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
SBP, ICS, P, PC
2. Develops an appreciation of the importance of coordinating care among multiple health professionals (nurses, physical therapists, social workers, counselors, psychologists, other physicians).
Direct patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
SBP, ICS, P
3. Demonstrates an appreciation of the importance of advocating for quality care for patients (pre-authorizations for medications, filing disability claims, etc).
Direct patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
SBP, ICS, P
4.* Develops an understanding of evidence-based cost-conscious patient care.
Direct patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
SBP, ICS, P
Goal 4. To enable trainees to enhance their interpersonal and communication skills. Fellow Objectives Instructional Strategies Assessment of Competence ACGME Competency Goals *
1. Develops an appreciation of the myriad challenges faced by patients with serious chronic illnesses, with a particular focus on the social, emotional, and economic burden of chronic disease.
Direct patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
ICS, P
2. Demonstrates ability to work effectively with colleagues and peers (including nurses, physical therapists, social workers, counselors, psychologists and other physicians) to coordinate the care of complex patients.
Direct patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
ICS, P
11
ROTATION: Stanford and VA Consultation Service Year: PGY 4, PGY 5
Goal 1. To enable rheumatology trainees to enhance their knowledge of the epidemiology, pathophysiology, clinical features, diagnosis, and management of a broad array of autoimmune and rheumatologic conditions.
Fellow Objectives Instructional Strategies Assessment of Competence ACGME Competency Goals *
1. Demonstrates knowledge of indications, limitations, and interpretation of laboratory tests (particularly autoantibodies) in the diagnosis of systemic autoimmune disease.
Direct patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
MK, PC
2. Demonstrates knowledge of the differential diagnosis and appropriate management of acute monoarticular arthritis.
Direct patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
MK, PC
3. Demonstrates knowledge of the differential diagnosis and appropriate management of acute and subacute polyarticular arthritis.
Direct patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
MK, PC
4. Demonstrates ability to diagnose and begin therapeutic intervention for the most commonly encountered rheumatic diseases, including: RA, SLE, Sjogren’s syndrome, myositis, systemic sclerosis, vasculitides, seronegative spondylarthritidies, infectious arthritides, crystal- associated diseases.
Direct patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
PC, MK
5. Demonstrates competence in differentiation of acute rheumatic disease exacerbations from infections and other processes (e.g. malignancy).
Direct patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
PC, MK
6. * Demonstrates interest in and willingness to review literature to guide management of rare rheumatic diseases; bone and cartilage disorders; hereditary, congenital, and
Direct patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
PC, MK, PLI
12
inborn errors of metabolism associated with rheumatic syndromes; nonarticular and regional musculoskeletal disorders; neoplasms and tumor-like lesions; and muscle diseases.
Goal 2. To allow trainees to enhance their knowledge of best-practice guidelines and quality indicators for the management of patients with rheumatologic conditions, and to learn to incorporate these metrics into clinical care. Fellow Objectives Instructional Strategies Assessment of Competence ACGME Competency Goals *
1. Demonstrates familiarity with commonly used medications in the treatment of rheumatologic conditions and potential acute adverse effects of these medications.
Direct patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
PC, MK
2. Demonstrates awareness of common co-morbidities among patients with systemic autoimmune disease— including increased risk of cardiovascular disease, osteoporosis, and increased risk of infection—and potential acute presentations of these processes.
Direct patient care Self-directed learning Review of trainee documentation
Global MedHub rating form by attending Attending review of fellow documentation Self-reflection assessment tool
SBP, PC
Goal 3. To familiarize trainees with the important systems-based practice issues at play in the care of patients with chronic, serious illness. Fellow Objectives Instructional Strategies Assessment of Competence ACGME Competency Goals *
1. Develops an appreciation of the importance of coordinating care among multiple health professionals (nurses, physical therapists, social workers, counselors, psychologists, other physicians).
Direct patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
SBP, ICS, P
2. Demonstrates an appreciation of the importance of advocating for quality care for patients (pre-authorizations for medications, filing disability claims, etc).
Direct patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
SBP, ICS, P
3. * Develops an understanding of evidence-based cost-conscious patient care.
Direct patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
SBP, ICS, P
13
Goal 4. To enable trainees to enhance their interpersonal and communication skills. Fellow Objectives Instructional Strategies Assessment of Competence ACGME Competency Goals *
1. Develops an appreciation of the myriad challenges faced by patients with serious chronic illnesses, with a particular focus on the social, emotional, and economic burden of chronic disease.
Direct patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
ICS, P
2. Demonstrates ability to work effectively with colleagues and peers (including nurses, physical therapists, social workers, counselors, psychologists and other physicians) to coordinate the care of complex patients.
Direct patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
ICS, P
3. Observes the trainee interview, examine, and discuss a plan with a patient, ensuring that the trainee demonstrates adequacy in all clinical competencies.
Direct patient care Global MedHub CEX rating by attending PC, MK, ICS, P
14
ROTATION: Santa Clara Valley Consultation Service Year: PGY 4, PGY 5
Goal 1. To enable rheumatology trainees to enhance their knowledge of the epidemiology, pathophysiology, clinical features, diagnosis, and management of a broad array of autoimmune and rheumatologic conditions.
Fellow Objectives Instructional Strategies Assessment of Competence ACGME Competency Goals *
1. Demonstrates knowledge of indications, limitations, and interpretation of laboratory tests (particularly autoantibodies) in the diagnosis of systemic autoimmune disease.
Direct patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
MK, PC
2. Demonstrates knowledge of the differential diagnosis and appropriate management of acute monoarticular arthritis.
Direct patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
MK, PC
3. Demonstrates knowledge of the differential diagnosis and appropriate management of acute and subacute polyarticular arthritis.
Direct patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
MK, PC
4. Demonstrates ability to diagnose and begin therapeutic intervention for the most commonly encountered rheumatic diseases, including: RA, SLE, Sjogren’s syndrome, myositis, systemic sclerosis, vasculitides, seronegative spondylarthritidies, infectious arthritides, crystal- associated diseases.
Direct patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
PC, MK
5. Demonstrates competence in differentiation of acute rheumatic disease exacerbations from infections and other processes (e.g. malignancy).
Direct patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
PC, MK
6. * Demonstrates interest in and willingness to review literature to guide management of rare rheumatic diseases; bone and cartilage disorders; hereditary, congenital, and
Direct patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
PC, MK, PLI
15
inborn errors of metabolism associated with rheumatic syndromes; nonarticular and regional musculoskeletal disorders; neoplasms and tumor-like lesions; and muscle diseases.
Goal 2. To allow trainees to enhance their knowledge of best-practice guidelines and quality indicators for the management of patients with rheumatologic conditions, and to learn to incorporate these metrics into clinical care. Fellow Objectives Instructional Strategies Assessment of Competence ACGME Competency Goals *
1. Demonstrates familiarity with commonly used medications in the treatment of rheumatologic conditions and potential acute adverse effects of these medications.
Direct patient care Didactic lectures Self-directed learning
Global MedHub rating form by attending Feedback on didactic presentations Self-reflection assessment tool
PC, MK
2. Demonstrates awareness of common co-morbidities among patients with systemic autoimmune disease— including increased risk of cardiovascular disease, osteoporosis, and increased risk of infection—and potential acute presentations of these processes.
Direct patient care Self-directed learning Review of trainee documentation
Global MedHub rating form by attending Attending review of fellow documentation Self-reflection assessment tool
SBP, PC
Goal 3. To familiarize trainees with the important systems-based practice issues at play in the care of patients with chronic, serious illness. Fellow Objectives Instructional Strategies Assessment of Competence ACGME Competency Goals *
1. Demonstrates culture competency in treating patients from diverse backgrounds and familiarity with the use of interpreters in caring for patients who are not comfortable communicating primarily in English.
Direct patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
SBP, ICS, P, PC
2. Develops an appreciation of the importance of coordinating care among multiple health professionals (nurses, physical therapists, social workers, counselors, psychologists, other physicians).
Direct patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
SBP, ICS, P
3. Demonstrates an appreciation of the importance of advocating for quality
Direct patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
SBP, ICS, P
16
care for patients (pre-authorizations for medications, filing disability claims, etc).
4. * Develops an understanding of evidence-based cost-conscious patient care.
Direct patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
SBP, ICS, P
Goal 4. To enable trainees to enhance their interpersonal and communication skills. Fellow Objectives Instructional Strategies Assessment of Competence ACGME Competency Goals *
1. Develops an appreciation of the myriad challenges faced by patients with serious chronic illnesses, with a particular focus on the social, emotional, and economic burden of chronic disease.
Direct patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
ICS, P
2. Demonstrates ability to work effectively with colleagues and peers (including nurses, physical therapists, social workers, counselors, psychologists and other physicians) to coordinate the care of complex patients.
Direct patient care Self-directed learning
Global MedHub rating form by attending Self-reflection assessment tool
ICS, P
ELECTIVE CURRICULA: YEAR TWO FELLOWS
NOTE: Electives are only available to PGY5 trainees. Stated Goals/Objectives are for PGY5 trainees
DERMATOLOGY
Attending: Dr David Fiorentino
Goals: To gain knowledge in immunologic theories, principles, and techniques and apply them to the
investigation, diagnosis, and treatment of immune-mediated skin diseases commonly seen by the
Rheumatologist
Objectives:
Medical Knowledge
Describe the immunologic milieu of the skin, and the immunopathogenesis of the immune-mediated
skin diseases commonly seen by Rheumatologists ( e.g. psoriasis, acute and chronic cutaneous lupus,
dermatomyositis, scleroderma, morphea, cutaneous expressions of vasculitis, panniculitis)
Provide a differential diagnosis for the pathologic findings of interface dermatitis
Link immunologic abnormalities to the current and proposed biologic agents used to treat immune-
mediated skin disease.
Discuss the differences in potency of topical corticosteroids, and provide examples of steroid strength in
each category
List the indications, dosing regimens, potential side effects, and follow-up monitoring strategies for the
dermatologic agents used to treat the cutaneous manifestations of SLE and dermatomyositis (e.g. anti-
malarials, thalidomide)
Demonstrate the ability to critically appraise and cite literature pertinent to the evaluation and
management of patients with immune-mediated skin diseases.
Patient Care
Effectively perform a comprehensive history and complete skin examination in patients with complaints
referable to the integument
Appropriately select and interpret laboratory and pathologic studies used in the evaluation of these
patients.
Construct a comprehensive treatment plan and assess response to therapy
Counsel patients and families concerning their diagnoses, planned diagnostic testing, and recommended
therapies.
Describe the indications and technique for (and perform if interested) diagnostic skin biopsy, and the
indications for deeper cutaneous biopsies (e.g. eosinophilic fasciitis)
Properly prescribe topical corticosteroids and oral systemic agents used in the management of immune-
mediated skin diseases.
Outline the management strategy for wound care of skin affected by digital ischemia and/or cutaneous
infarction (i.e., from vasculopathy)
Recognize and develop strategies to manage the psychological impact of immune-mediated skin
diseases
Practice-based Learning and Improvement
Effectively use the knowledge gained from the evaluation and management of Dermatology Clinic
patients to guide patient care decisions in their own continuity clinic
Demonstrate ability to critically assess the scientific literature regarding immune-mediated skin diseases
Set and assess individualized learning goals.
Analyze clinical experience and employ a systematic methodology for improvement
Develop and maintain a willingness to learn from errors, and use errors to improve the system or
processes of care.
Systems-based Practice
Address disease based and external systems that affect the health care of patients with immune-
mediated skin diseases.
Discuss how chronic immune-mediated skin disorders impact medical disability and maintenance of
health care insurance coverage.
Demonstrate effective collaboration with Dermatology clinicians, and formulate a strategy for
subspecialty consultation including appropriate evaluation prior to referral.
Educate Dermatology clinicians in the systemic manifestations and evaluation of patients with
rheumatic diseases seen in the Dermatology patient care setting.
Interpersonal Skills and Communication
Demonstrate the ability to discuss diagnostic testing with patients and convey management
recommendations clearly and with an empathetic and understanding manner.
Reliably and accurately communicate the patient’s and their family’s views and concerns to the
attending
Counsel patients, families, and colleagues regarding side effects, and appropriate use of specific
therapies, providing written documentation when appropriate
Professionalism
Be prompt and prepared for clinic
Recognize the importance of patient primacy, patient privacy, patient autonomy, informed consent, and
equitable respect and care to all.
Respect patients and their families, staff, and colleagues
Model ethical behavior by reporting back to the attending key clinical findings, following through on
clinical questions, laboratory testing and other patient care issues, and recognizing potential conflicts of
interest.
Demonstrate integrity, honesty, and openness in discussion of therapeutic options with patients and
respect for patient’s preferences and multicultural differences.
ELECTIVE CURRICULA: YEAR TWO FELLOWS
OSTEOPOROSIS/METABOLIC BONE DISEASE ELECTIVE
Attendings: Stanford Endocrinology Staff
Goals: Gain knowledge in the pathophysiology of bone loss and the pharmacology of agents used to
prevent and correct it. To gain experience in the application of this knowledge to the investigation,
diagnosis, and treatment of osteoporosis.
Objectives:
Medical Knowledge
Describe the anatomy and physiology of bone, including bone development and structure. Describe the
cellular basis of bone turnover and remodeling, and the hormonal and cytokine regulation of same.
Discuss the cellular and cytokine crosstalk between the immune system and bone (osteoimmunology),
and the potential mechanisms of bone destruction in inflammatory arthritis.
List the factors that contribute to bone quality, and the risk factors for fracture.
Discuss indications and specific tests to evaluate for bone mineral density (e.g. DEXA), bone remodeling
activity (e.g. serum and urinary bone metabolism markers), and fracture risk (e.g. FRAX score).
Describe the epidemiology and clinical presentation of osteoporosis and osteomalacia.
Provide both a general and gender-specific differential diagnosis for secondary osteoporosis.
Identify the mechanism of action, indications, dosing, required monitoring, and therapy-related
complications of medications commonly used to prevent and treat bone loss.
Provide examples of physical activities most likely to maintain and/or increase bone density.
Demonstrate the ability to critically appraise and cite literature pertinent to the evaluation and
management of patients with or at risk for osteoporosis.
Patient Care
Effectively perform a comprehensive history and complete physical examination in patients with
suspected bone loss.
Appropriately select and interpret laboratory, imaging, and pathologic studies used in the evaluation of
these patients.
Construct a comprehensive treatment plan, including appropriate medications (e.g. calcium, vitamin D,
bone anti-resorptive or anabolic agents), and nonpharmacologic measures (e.g. exercise activities) for
the patient with low bone density, and assess response to therapy.
Counsel patients and families concerning their diagnosis, planned diagnostic testing and recommended
therapies.
Practice Based Learning and Improvement
Effectively use the knowledge gained from the evaluations and management of patients with bone loss
to guide patient care decisions in the trainees own continuity patients.
Demonstrate ability to critically assess the scientific literature regarding osteoporosis and disorders
affecting the maintenance of normal bone density.
Set and assess individualized learning goals.
Analyze clinical experience and employ a systematic methodology for improvement.
Develop and maintain a willingness to learn from errors, and use errors to improve the system or
processes of care.
Systems Based Practice
Address disease-based and external systems that affect the health of patients with osteoporosis.
Discuss how the sequelae of osteoporosis impact medical disability and maintenance of health care
insurance coverage.
Demonstrate effective collaboration with bone health clinicians, and formulate a strategy for
subspecialty consultation which includes appropriate evaluation prior to referral.
Educate bone health clinicians in the systemic manifestations and the evaluation of patients with
rheumatic diseases who are seen in the osteoporosis patient care setting.
Interpersonal Skills and Communication
Demonstrate the ability to discuss diagnostic testing with patients and convey management
recommendations clearly and with an empathetic and understanding manner
Reliably and accurately communicate the views and concerns of patients and their families to the
attending physician.
Counsel patients, families, and colleagues regarding side effects and appropriate use of specific
therapies, providing written documentation when appropriate.
Professionalism
Be prompt and prepared for clinic.
Recognize the importance of patient primacy, patient privacy, patient autonomy, informed consent,
and equitable respect and care to all.
Respect patients and their families, staff, and colleagues.
Model ethical behavior by reporting back to the attending key clinical findings, following through on
clinical questions, laboratory testing and other patient care issues, and recognizing potential conflicts of
interest.
Demonstrate integrity, honesty, and openness in discussion of therapeutic options with patients and
respect for patient’s preferences and multicultural differences.
ELECTIVE CURRICULA: YEAR TWO FELLOWS
PHYSICAL MEDICINE AND REHABILITATION (PHYSIATRY)
Attendings: S.O.A.R Physiatry staff
Goals: The goal of a Physiatry rotation within a Rheumatology training program is to train fellows to be
knowledgeable in areas of rehabilitative care, including but not limited to exercise therapy, splinting and
orthotic devices and mobility assistive devices. Other goals are to: 1) train fellows in the care of non-
inflammatory axial disorders through the use of injection therapies (e.g. epidural steroids),thermal,
electrical (e.g. TENS), and non-traditional modalities (e.g. acupuncture), 2) train fellows in the evaluation
of functional capacity, and 3) help fellows to gain an understanding of appropriate use of Physiatry
referral services.
Objectives
Medical Knowledge
Define the consequences of disease as they apply to rehabilitation, including pathophysiology,
impairment, functional limitation, disability, and handicap.
Describe the anatomy and physiology of the spine, including bone, disk and nerve structure.
Describe the pathophysiology of degenerative conditions of the spine.
Construct a comprehensive treatment plan for patients with known degenerative spinal disorders.
Understand the evidence base for and against the use of commonly employed therapies for
degenerative spinal disorders.
Discuss the role of physical therapy in the care of ambulatory patients with a variety of musculoskeletal
disorders.
Discuss the clinical expression of the non-traumatic musculoskeletal diseases encountered in the
outpatient Physiatry setting.
Explain the differences between isometric, isotonic, and isokinetic exercise and provide examples for
their respective indications.
Identify the indications for selected rehabilitative therapies.
Demonstrate ability to critically appraise and cite literature pertinent to the evaluation and treatment of
outpatients in the rehabilitative setting.
Patient Care
Effectively perform a musculoskeletal examination, focusing on functional assessement, on ambulatory
patients in the rehabilitative setting.
Outline the components of a comprehensive therapy treatment plan, and assess response to therapy.
Outline the components of a comprehensive treatment plan for patients with degenerative spinal
disorders.
Write an exercise prescription.
Interpret and apply the results of a functional capacity evaluation.
Practice Based Learning and Improvement
Effectively use the knowledge gained from the evaluation and management of ambulatory rehabilitative
and spinal degenerative disease patients to guide patient care decisions in the trainees own continuity
patients.
Demonstrate ability to critically assess the scientific literature regarding musculoskeletal conditions seen
in the outpatient rehabilitative setting.
Set and assess individualized learning goals.
Analyze clinical experience and employ a systematic methodology for improvement.
Develop and maintain a willingness to learn from errors, and use errors to improve the system or
processes of care.
Systems Based Practice
Address how certain diagnose and external systems affect the health care of patients with
musculoskeletal conditions requiring ambulatory rehabilitative care.
Discuss how musculoskeletal conditions requiring rehabilitation impact medical disability and
maintenance of health care insurance coverage.
Demonstrate effective collaboration with Physiatrists and Physical Therapists, and formulate a strategy
for effective referral.
Educate Physiatrists and Physical Therapists in the systemic manifestations and evaluation of patients
with rheumatic diseases seen in the rehabilitation patient care setting.
Interpersonal Skills and Communication
Demonstrate the ability to discuss rehabilitation therapy with patients and convey management
recommendations clearly and with an empathetic and understanding manner.
Reliably and accurately communicate the patient’s and their family’s views and concerns to the
attending and to the therapist.
Counsel patients, families, and colleagues regarding side effects, and appropriate use of specific
therapies, providing written documentation when appropriate.
Professionalism
Be prompt and prepared for clinic.
Recognize the importance of patient primacy, patient privacy, patient autonomy, informed consent,
and equitable respect and care to all.
Respect patients and their families, staff, and colleagues.
Model ethical behavior by reporting back to the attending key clinical findings, following through on
clinical questions, laboratory testing and other patient care issues, and recognizing potential conflicts of
interest.
Demonstrate integrity, honesty, and openness in discussion of therapeutic options with patients and
respect for patient’s preferences and multicultural differences.
ELECTIVE CURRICULA: YEAR 2 FELLOWS
PODIATRY
Attending: Dr Lawrence Oloff and partners (SOAR)
Goals: The specialty of Podiatry deals with a wide variety of mechanical, inflammatory, and degenerative
diseases of the ankle and foot. The purpose of a Podiatry rotation within a Rheumatology training
program is to train fellows to be knowledgeable in the areas of Podiatry, including but not limited to
foot and ankle deformities, orthotic options, and the manifestations and therapies of rheumatic and
musculoskeletal diseases in the foot and ankle. The fellow will gain an understanding of the appropriate
referral of the patient to a Podiatrist.
Objectives
Medical Knowledge
Describe the structure and function of the ankle, hind foot, midfoot, and forefoot.
Describe the epidemiology, natural history, clinical expression, pathology, pathogenesis, and approach
to management of the musculoskeletal diseases encountered in the Podiatry outpatient setting,
including but not limited to heel pain , Achilles tendinitis, plantar fasciitis, tarsal tunnel syndrome,
Charcot arthropathy, midfoot osteoarthritis, hallux valgus, and metatarsalgia of various etiologies (e.g
rheumatoid arthritis, gout, and Morton’s neuroma).
Distinguish localized podiatric disorders from systemic rheumatic diseases with manifestations in the
foot and/or ankle.
Interpret radiologic studies used in the evaluation of podiatric outpatients with musculoskeletal
conditions.
Demonstrate ability to critically appraise and cite literature pertinent to the evaluation of podiatric
outpatients.
Identify the indications for podiatric surgery (e.g. correction of hallux valgus, metatarsal head resection
in rheumatoid arthritis).
Discuss the roles of physical therapy and orthotic appliances in the care of ambulatory patients with
musculoskeletal conditions of the foot and/or ankle.
Patient Care
Effectively perform a comprehensive history and thorough musculoskeletal examination of the foot and
ankle.
Appropriately select and interpret laboratory, radiologic, and pathologic studies used in the evaluation
of podiatric patients.
Construct a comprehensive treatment plan, including when appropriate, immobilization, splinting, and
orthotic appliances and assess response to therapies of same.
Counsel patients and families concerning their diagnosis, planned diagnostic testing, and recommended
therapies.
Recognize and develop strategies to manage the psychological and work impact of musculoskeletal
diseases affecting the foot and ankle
Demonstrate proficiency in procedures, including arthrocentesis and injections, compensated polarizing
microscopy, and interpretation of synovial fluid analyses.
Practice Based Learning and Improvement
Effectively use the knowledge gained from the evaluation and management of podiatric clinic patients
to guide patient care decisions in the trainees own continuity patients.
Demonstrate ability to critically assess the scientific literature regarding musculoskeletal conditions of
the foot and ankle.
Discuss how chronic musculoskeletal conditions of the foot and ankle impact medical disability and
maintenance of health care insurance.
Demonstrate effective collaboration with Podiatrists, and formulate a strategy for effective referral to
Podiatrists to include appropriate pre-referral evaluation.
Educate Podiatrists in the systemic manifestations and evaluation of patients with rheumatic diseases
seen in the Podiatry Clinic.
Interpersonal Skills and Communication
Demonstrate the ability to discuss podiatric diagnostic testing with patients and convey management
recommendations clearly and with an empathetic and understanding manner.
Reliably and accurately communicate the patient’s and their family’s views and concerns to the
attending.
Counsel patients, families, and colleagues regarding side effects, and appropriate use of specific
therapies, providing written documentation when appropriate.
Professionalism
Be prompt and prepared for clinic.
Recognize the importance of patient primacy, patient privacy, patient autonomy, informed consent,
and equitable respect and care to all.
Respect patients and their families, staff, and colleagues.
Model ethical behavior by reporting back to the attending key clinical findings, following through on
clinical questions, laboratory testing and other patient care issues, and recognizing potential conflicts of
interest.
Demonstrate integrity, honesty, and openness in discussion of therapeutic options with patients and
respect for patient’s preferences and multicultural differences.
ELECTIVE CURRICULA: YEAR 2 FELLOWS
Women’s Health‐ VA
Attending physician: Dr. Lorinda Chung
Goals:
1. To enable rheumatology trainees to enhance their knowledge of the epidemiology, pathophysiology, clinical
features, diagnosis, and management of rheumatologic diseases in female patients
2. To allow trainees to enhance their knowledge of best‐practice guidelines and quality indicators for the
management of female patients with rheumatologic disease and to learn to incorporate these metrics into
clinical care.
3. To familiarize trainees with the important systems‐based practice issues at play in the care of female patients
with a chronic, serious illness.
4. To enable trainees to cultivate an appreciation of research ethics.
5. To enable trainees to enhance their interpersonal and communication skills.
Objectives
Medical Knowledge:
1. Demonstrates knowledge of indications, contraindications, limitations, and interpretation of results of diagnostic and therapeutic procedures specific to female patients with rheumatologic disease
2. Demonstrates competency in the diagnosis and management of both acute processes (disease flares, infections) and chronic disease manifestations in female patients with rheumatologic disease.
3. Demonstrates knowledge of screening for and treatment of long‐ term complications in female patients with rheumatologic disease, including cardiovascular disease and osteoporosis. Patient Care:
1. Demonstrates an understanding of the patient consent process and the complexities for both patients and
Interpersonal Skills and Communication:
1. Develops an appreciation of the importance of coordinating care among multiple health professionals (nurses, physical therapists, social workers, counselors, psychologists, other physicians). 2. Demonstrates an appreciation of the importance of advocating for quality care for patients (pre‐authorizations for medications, filing disability claims, etc.). System‐based practice:
1. Demonstrates familiarity with best‐practice guidelines and quality indicators for the management of female
patients with rheumatologic diseases including screening for disease‐related and treatment‐ related
complications that lead to long‐term morbidity (osteoporosis, cardiovascular disease, viral infections).
2. Demonstrates an understanding of current guidelines for the management of rheumatologic disease in female patients as it pertains to family planning, pregnancy, breast‐feeding, and contraception. Professionalism:
1. Develops an appreciation of the myriad challenges faced by female patients with rheumatologic disease
with a particular focus on the social, emotional, and economic burden of chronic disease.
2. Demonstrates ability to work effectively with colleagues and peers (including nurses, physical therapists, social workers, counselors, psychologists and other physicians) to coordinate the care of female patients with rheumatologic
ELECTIVE CURRICULA: YEAR 2 FELLOWS
Sports Medicine‐ Stanford
Attending physician: Dr. Dev Mishra
Goals: Fellows with observe and participate in the care of the sports medicine patient. The fellow will
participate in the initial evaluation, peri‐operative care, and non‐operative treatment of orthopedic
injuries and diseases, including those of the knee, shoulder, elbow and hip in addition to general
orthopedics and sports medicine. At the completion of the rotation, the fellow should be competent in
performing a complete and thorough examination of the shoulder, elbow, hip, and knee. The fellow
should also be competent in identifying various sports pathology and initiating the appropriate work‐up.
Objectives
Medical Knowledge: Topics to be covered during this elective include:
1. Biomechanics of ligaments
2. Shoulder, elbow and knee biomechanics
3. Common elbow pathology, including ligament insufficiency, overuse syndrome
4. Meniscal pathology
5. Patellofemoral disorders and treatment
6. Stress fractures
7. Overuse syndrome and various tendonitis
8. Rotator cuff pathology
9. Acromioclavicular joint pathology
10. Impingement syndrome
11. Shoulder stiffness
12. Shoulder instability and treatment
13. Femoroacetabular treatment
14. Hip labral tears
15. Hip biomechanics
16. Epicondylitis
Patient Care: The fellow will gain the skills to properly evaluate for the above and in the initial non‐
surgical management.
Practice Based Learning and Improvement: The fellow will demonstrate competence in the ability to
evaluate their own performance and utilize feed‐back to improve their performance in the clinic.
Interpersonal Skills and Communication: The fellow will demonstrate competence in working with and
communicating effectively within a health care team comprising of physical therapists, nurses, patient.
System‐based practice: The fellow will appropriately delegate resource management and use of outside
services such as physical therapy, MRI, and interventional radiology.
ELECTIVE CURRICULA: YEAR 2 FELLOWS
Ophthalmology‐ Stanford
Attending physician: Dr. Ira Wong
Goals:
1. Learn to recognize the normal eye examination and to be able to recognize basic deviations
from normality and be reliable in bringing them to the attention of an ophthalmologist
2. Evaluate ophthalmologic conditions that are unique to patients with rheumatologic disease.
Objectives
Medical Knowledge:
1. Gain knowledge of eye anatomy, normal physiology and changes associated with aging and
rheumatologic disease
2. Develop a basic understanding of the pathophysiology, clinical presentation, natural history, and
therapy for the following conditions:
a. Conjunctivitis
b. Iritis
c. Glaucoma
d. Scleritis
3. Understand the use of the following medications:
a. Antibiotics
b. Corticosteroids
c. Glaucoma agents
4. Understand basic interpretations from laboratory and imaging studies, such as fluorescein
angiography, ocular ultrasound, MRI and CT relevant to the diagnosis and treatment of the
above conditions
Patient Care:
1. Demonstrate the ability to take a focused ophthalmologic history and incorporate information
into the electronic medical record
2. Perform an appropriately‐targeted physical exam
Practice Based Learning and Improvement:
1. Be able to access current clinical practice guidelines and apply evidence based strategies to
patient care
2. Learn how the ophthalmologist and rheumatologist function as a part of the patient care team
Interpersonal Skills and Communication:
1. Develop interpersonal skills to educate and counsel patients, and where appropriate promote
behavioral change
Professionalism:
1. Educate patients and their families in a manner respectful of gender, cultural, religious,
economic, and educational differences on choices regarding their care
2. Demonstrate commitment to carrying out professional responsibilities
System‐based Practice:
1. Develop a basic understanding that diagnostic and treatment decisions involve cost and risk and
affect quality of care
2. Learn about alternative care strategies, taking into account the social, economic, and
psychological factors that affect patient health and use of resources.
ELECTIVE CURRICULA: YEAR 2 FELLOWS
Orthopedic Surgery‐ Stanford
Attending physician: Drs. William Maloney and Stuart Goodman
Goals:
1. To educate fellows in the diagnosis, surgical and non‐surgical treatment and outcome of arthritis
and adult reconstructive cases
2. To evaluate and treat common orthopedic problems
3. To understand the role of an orthopedic consultant in the care of the medical patient
4. To become proficient in the examination of joints
5. To understand the role of physical therapy in the care of patients with orthopedic problems.
Objectives
Medical Knowledge: Know the basic and clinical science on which adult reconstructive surgery is
grounded
Patient Care: The fellow may be exposed to various orthopedic surgical procedures as well as become
aware of the perioperative management of such patients.
Interpersonal Skills and Communication: The fellow should become aware of the how to effectively
communicate and counsel patients regarding arthroplasty and the risks and benefits.
System‐based practice: Ability to independently access and utilize outside resources such as home
health care and anti‐coagulation services in the care and management of this patient population.
ELECTIVE CURRICULA: YEAR 2 FELLOWS
MSK Ultrasound – VMC or Stanford
Attending physician: Drs. Veronika Sharp and Robert Fairchild
Goals: Upon completion of the ultrasound rotation, the fellow will be able to:
1. Describe the normal ultrasound anatomy of various joints and recognize the ultrasound
characteristics of various pathologic conditions.
2. Scan various joints using appropriate technique.
3. Have familiarity in performing ultrasound‐guided procedures such as aspiration or injections
Objectives
Medical Knowledge:
1. Learn the indications for musculoskeletal ultrasound
2. Learn to use the diagnostic and therapeutic options of musculoskeletal ultrasound appropriately
3. Be able to identify typical ultrasound pathology encountered in osteoarthritis, gout, CPPD,
rheumatoid arthritis, seronegative arthritis, as well as tendinopathies and neuropathies.
Patient Care:
1. Be able to perform standardized ultrasound scans and identify relevant structures of the hands,
wrists, feet, and knees. Proficiency in additional areas (elbows, shoulders, hips, and ankles) may
be pursued, time permitting.
2. Learn how to perform ultrasound‐guided interventions including aspiration and injection.
Practice Based Learning and Improvement:
1. Learn how to adjust equipment settings and utilize Doppler ultrasound to assess inflammatory
activity.
Interpersonal and Communication Skills:
1. Communicate effectively and compassionately with patients
2. Effectively communicate patients’ needs to other providers
System‐based Practice:
1. Learn proper machine care and maintenance as well as issues related to documentation and billing.
2. Understand appropriate referrals for musculoskeletal ultrasound
Professionalism:
1. Interact with patients and colleagues in a respectful manner
2. Maintain patient confidentiality and HIPAA guidelines
RHEUMATOLOGY FELLOWSHIP PRIVATE PRACTICE ELECTIVE
Stanford University Rheumatology Fellowship Program
Michael Lyon MD – Associate Professor of Rheumatology, Fellowship Program Director
Elaine Lambert MD; Amy Elliott MD; Cathy Riker MD and/or alternative program-approved private practice GOALS:
• To gain expertise in the outpatient evaluation and management of patients with a broad spectrum of musculoskeletal and rheumatic diseases.
• To develop an understanding of the variable demographics of the patients seen in the outpatient private practice setting.
• To gain experience and expertise in the care of acute rheumatologic issues before patients reach tertiary care centers.
• To gain exposure to the broad network of physicians and community outside of the academic center.
• To develop a knowledge and comfort with patient coding, billing and the business aspects of medicine.
OBJECTIVES:
MEDICAL KNOWLEDGE
• Describe the epidemiology, genetics, pathology and clinical expression of the rheumatic diseases encountered in the outpatient setting
• Develop and describe the rheumatologic as well as non-rheumatologic differential diagnoses for acute rheumatologic presentations including new onset arthritis, rashes, fevers and summarize an approach to the evaluation of multi-organ inflammatory disorders
• Develop a clear knowledge and be able to discuss the biochemical mechanisms of action, rationale for treatment and side effects of all DMARDs and/or biologic rheumatic therapies.
• Demonstrate the ability to critically appraise and cite literature pertinent to the evaluation of outpatients
• Describe and discuss the roles of adjunctive services for the treatment and support of patients with rheumatic disease including physiatry, hand therapy, physical therapy, occupational therapy and orthopedic surgery.
PATIENT CARE
• Effectively perform a comprehensive history and physical examination in patients with rheumatic symptoms or abnormal immunologic tests.
• Appropriately select and interpret laboratory, imaging and pathologic studies used in the evaluation of rheumatic disorders.
• Demonstrate proficiency in procedures including arthrocentesis and injections, polarized microscopy and interpretation of synovial fluid analysis.
• Counsel patients concerning their diagnosis and expected treatment while setting appropriate expectations.
PRACTICE-BASED LEAERNING AND IMPROVEMENT
• Effectively use EMR systems to manage information and enhance both patient and physician education.
• Demonstrate ability to critica y assess the scientific literature
• Develop a willingness to learn from errors and use errors to improve the system or processes of care.
SYSTEMS-BASED PRACTICE
• Discuss how the health care system in the community setting affects the management of outpatients with rheumatic diseases.
• Summarize the private practice model of ambulatory health care delivery, including the fundamentals of office and personnel management and budgeting.
• Identify problems in delivery of optimal patient care and propose corrective actions
• Determine cost-effectiveness of alternative proposed interventions and design cost-effective plans
• Demonstrate awareness of the impact of diagnostic and therapeutic recommendations on the health care system, cost of the procedure, insurance coverage and resources utilized.
INTERPERSONAL SKILLS AND COMMUNICATION
• Approach patients with an empathetic and understandable manner and demonstrate effective listening skills with patients and their family members
• Counsel patients and their families regarding side effects and appropriate use of specific medications, providing
written documentation when appropriate.
PROFESSIONALISM
• Recognize the importance of patient privacy, informed consent and respect for patient care by relaying clear instructions and expectations
• Be prompt and prepared for clinic exhibiting a clear interest in participating
• Model ethical behavior by reporting back to the attending and referring providers key clinical findings, following through on clinical questions, laboratory testing and other patient care issues and recognizing potential conflicts of interest.
RHEUMATOLOGY FELLOWSHIP RADIOLOGY ELECTIVE
Stanford University Rheumatology Fellowship Program
Michael Lyon MD – Associate Professor of Rheumatology, Fellowship Program Director
Musculoskelatal Imaging; Stanford Department of Radiology Christopher
Beaulieu M.D., Ph.D; Kathryn Stevens MD; Geoffrey Riley MD
GOALS:
To gain knowledge in the use of radiological studies applicable to the evaluation and management of patients with musculoskeletal and rheumatic disorders
OBJECTIVES:
MEDICAL KNOWLEDGE
• Define appropriate indications for the use of different imaging modalities including plain film, musculoskeletal ultrasound, CT scan, MRI, radionuclide scans of the bone and DEXA
• Understand the rationale for the selection of specific view requested in ordering plain film radiographs for selected rheumatic and musculoskeletal conditions
• Recognize the radiographic abnormalities seen in avascular necrosis, sacroiliitis, erosive joint disease, crystalline arthropathies, degenerative joint disease, and spine disease as seen on plain film, CT scan, and MRI.
• Discuss the indications and rationale for radiologic tests used to evaluate vasculitis including CTA, MRAand PET
PATIENT CARE
• Apply the knowledge acquired during this rotation to enhance the care of patients with rheumatic and musculoskeletal diseases
PRACTICE-BASED LEAERNING AND IMPROVEMENT
• Use the knowledge gained from the interpretation of radiological studies to guide patient care decisions and cost- effective stratagies
• Develop and maintain a willingness to learn from errors and use them to improve the system and/or processes of care
SYSTEMS-BASED PRACTICE
• Demonstrate effective collaboration with radiology physicians and strive for improvements in communication
• Educate radiology physicians in the systemic manifestations and evaluation of patients with rheumatic diseases
INTERPERSONAL SKILLS AND COMMUNICATION
• Effectively discuss and communicate radiologic results with patients and rheumatology co eagues
PROFESSIONALISM
• Recognize the importance of patient privacy, informed consent and respect for patient care by relaying clear instructions and expectations
• Model ethical behavior by reporting accurately to the attending key radiographic and clinical findings
• Demonstrate integrity, honesty and openness in discussion of radiological findings with faculty and staff
CURRICULUM: YEAR TWO PEDIATRIC OUTPATIENT CLINIC ELECTIVE
Goals: The educational purpose of the pediatric clinic elective will be for senior fellows to gain
expertise in the outpatient evaluation and management of pediatric patients with a broad spectrum of
musculoskeletal and rheumatic diseases. Trainees should develop sensitivity to the critical role of the
family dynamic in the presentation and ongoing care of the child with rheumatic disease. Trainees
should be able to recognize multisystem aspects of rheumatic disease in the pediatric population, and
become familiar with the particular importance in pediatrics of multidisciplinary care for patients and
families.
Objectives
Medical Knowledge:
List classification and diagnostic criteria for major disorders seen in the pediatric Rheumatology clinic.
Explain similarities and differences between adults and children with regards to various rheumatologic
syndromes.
Describe the epidemiology, genetics, natural history, clinical expressions (including subtypes), pathology,
and pathogenesis of the rheumatic disorders typically encountered in a pediatric outpatient setting.
Summarize an approach to the evaluation of multi-organ inflammatory disorders in children
Discuss the biochemical mechanisms of action, indications, potential adverse effects, and pediatric
dosing of the pharmacologic agents used to treat pediatric outpatient musculoskeletal and rheumatic
disorders.
Distinguish non-rheumatic mimics from true rheumatic diseases in children.
Interpret diagnostic tests used in the evaluation of outpatient pediatric patients with suspected
rheumatic and musculoskeletal diseases.
Demonstrate ability to critically appraise and cite literature pertinent to the evaluation of outpatient
pediatric patients
Patient Care
Effectively perform a comprehensive history and complete physical examination in children with
rheumatic symptoms or abnormal immunologic tests.
Appropriately select and interpret laboratory, imaging, and pathologic studies for the evaluation of
common pediatric disorders.
State the indications for arthrocentesis and injection procedures in children
Construct a comprehensive treatment plan and assess response to therapy
Counsel patients and their families concerning diagnosis, planned testing, and recommended therapies
Prescribe, based on weight and/or body surface area, pharmacotherapies for use in children
Coordinate Rheumatology clinic follow up care and communicate effectively with the patient’s primary
care physician and/or referring provider
Practice-based learning and improvement:
Effectively use technology to manage information for patient care
Integrate and apply knowledge obtained from multiple sources to the care of children
Demonstrate ability to critically assess the scientific literature
Set and assess individualized learning goals
Analyze clinical experience and employ a systematic methodology for improvement
Identify an example of how diagnosis or management of a pediatric clinic patient differs from that of an
adult patient with the same or a similar rheumatic condition
Systems-based practice:
Discuss how the clinic system affects the management of children with rheumatic diseases
Identify problems in delivery of optimal patient care and propose corrective actions
As a consultant, learn to facilitate coordination of the unique multi-disciplinary aspects of pediatric
outpatient rheumatologic care.
Determine cost-effectiveness of alternate proposed interventions
Design cost-effective plans based on knowledge of best practices.
Demonstrate awareness of the costs to and impacts of specialty consultations, procedures, and
therapies on the overall health care system.
Understand insurance coverage issues relative to delivery of the various aspects of specialty care in the
pediatric rheumatic disease population
Identify ancillary care appropriate for treatment of outpatient pediatric rheumatic disorders
Interpersonal skills and communication:
Show sensitivity to the particular needs of parents and children when sharing difficult news
Adopt effective strategies to gain the trust of pediatric patients and their families
Employ effective skills of listening and speaking with patients, families, and other members of the health
care team
Reliably and accurately communicate the patient’s and his/her family’s views and concerns to the
attending.
Compose clear and timely consultation reports including a precise diagnosis whenever possible,
differential diagnosis when appropriate and recommend follow up or additional studies
Communicate clearly with the primary care and/or referring provider regarding diagnostic and /or
treatment recommendations.
Counsel patients, families, and colleagues regarding the side effects and appropriate use of specific
medications, and obtain parental consent and patient assent for treatment, providing written
documentation when appropriate.
Supervise medical students’ and residents’ communications with families, patients, and members of the
health care team.
Professionalism:
Be prompt and prepared for clinic
Recognize the importance of patient primacy, patient privacy, patient autonomy, informed consent, and
equitable respect and care to all.
Respect patients and their families, staff, and colleagues
Model ethical behavior by reporting back to the primary care team on key clinical findings, as well as
following through on clinical questions, laboratory testing, and other patient care issues.
Demonstrate integrity, honesty, and openness in discussion of therapeutic options with patients and
their families
Respect patient and family preferences, recognizing multicultural issues that may impact patient care
and decision making
Demonstrate sensitivity to patients’ age-specific needs.
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STANFORD DICTATION
INSTRUCTIO
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