Internal medicine residents ‘lack confidence’ in rheumatology topics, want to learn more
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Key takeaways:
- Residents said key topics in a rheumatology rotation were ordering and interpreting autoimmune serologies and musculoskeletal exams.
- More work can be done to reduce the confidence gap, according to the researchers.
Many internal medicine residents report interest in learning more about rheumatology, but “lack confidence” in specific rheumatology matters, according to data published in BMC Medical Education.
“The goal of the rheumatology rotation during Internal Medicine (IM) residency is to develop competency in work-up and treatment of common rheumatologic conditions,” Lauren He, MD, of the department of medicine at the University of Chicago Medical Center, and colleagues wrote. “Previous studies have suggested that primary care physicians do not feel comfortable diagnosing and managing rheumatologic diseases, with only one third of providers reporting being very confident in co-managing patients with rheumatoid arthritis (RA) despite the majority of providers treating these patients.”
To identify what areas of internal medicine residency training can be altered to improve the confidence of residents in matters of rheumatic diseases, He and colleagues conducted an electronic survey. The survey was emailed to all internal medicine residents, including pediatric residents, as well as rheumatology attendings and fellows, at the University of Chicago. The researchers used Research Electronic Data Capture (REDCap) to conduct the survey.
Rheumatology attendings and fellows were asked to consider and rank 10 topics in their specialty from most to least important to learn during an internal medicine residence. The topics included crystalline arthropathies, RA, systemic lupus erythematosus, spondyloarthropathies, vasculitis and other ANA-associated diseases such as Sjögren’s syndrome and scleroderma.
The survey measured the confidence levels of internal medicine residents in providing treatment to patients with rheumatic diseases on a 10-point scale. Participating residents were instructed to rate their confidence levels for each included topic. Finally, residents were asked about their preferred teaching methods. For the purposes of this survey, these included situations for inpatient and outpatient learning opportunities.
A total of 11 rheumatology attendings or fellows, as well as 39 internal medicine residents, completed the survey. Among the residents who completed the survey, 13 (37%) had completed a rheumatology rotation in medical school, while 23 (66%) had completed a rheumatology rotation during residency. According to the researchers, the median confidence interval among participants for treating patients with rheumatic diseases was six (3.6-7.5) for inpatients and five (3.7-6.5) for outpatients.
Rheumatology attendings or fellows reported that the most important topics for internal medicine residents to learn during rotation were ordering and interpreting autoimmune serologies, as well as how to properly conduct a musculoskeletal exam. Finally, the preferred method for learning among residents at an inpatient setting was bedside teaching, while case reports were the preferred method for outpatient learning.
“To our knowledge, this is the first study to provide insight into the gaps of rheumatology learning identified by residents and their preferred learning methods to fill these gaps,” they wrote. “Internal medicine residents lack confidence across topics in rheumatology, however many have a desire to learn more about the field.
“Information gathered using this framework can be used to determine trainee confidence in rheumatology (or any subspecialty) and highlight opportunities to improve existing curricula,” they added. “These results may help guide more effective inpatient and outpatient teaching strategies in rheumatology, as informed – for the first time – by learner and teacher preferences.”
Perspective
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David A. McLain, MD, MACR, FACP, FRCP
I was very fortunate as a first- and second-year internal medical resident at Barnes-Jewish Hospital/ Washington University, in St. Louis, to have Bevra Hahn, MD, as an attending. I had been exposed to rheumatology at Tulane University, and again at Ochsner Medical Center, both in New Orleans, and I found it fascinating. Having a mentor like Bevra Hahn convinced me that rheumatology was for me. The present article reveals that many internal medicine residents are not exposed to rheumatology in their training and do not feel confident in their ability to treat common rheumatology problems.
Most rheumatology problems are handled in the outpatient area, and, per this article, internal medicine residents frequently do not get this exposure either. The Physician Education and Assessment Center, a national platform used by 294 internal medicine programs in the United States, has only two musculoskeletal modules — one on back pain and one on knee and hip pain.
Medical school exposure to rheumatology was not covered in this article, but there are articles detailing the limitations in the pre-clinical exposure and the attempts to increase the time devoted to musculoskeletal examination, rheumatology and autoimmunity.
Although musculoskeletal complaints account for one-quarter of primary care and ED visits, only 2% of the U.S. medical school curriculum is devoted to musculoskeletal disease. In one study, California medical schools devoted an average of about 60 hours to musculoskeletal medicine, of which more than half was spent covering anatomy.
Meanwhile, the primary instructor for musculoskeletal medicine was a clinician only one-third of the time. In addition, roughly one-half of schools offered a dedicated musculoskeletal physical exam course, and no schools required students to complete a clinical rotation in musculoskeletal medicine.
Past American College of Rheumatology President Ken Saag noted that it is estimated that 50% of current U.S. rheumatologists will retire in the next 10 years, leading to a 25% reduction of our work force. With limited exposure in medical school and internal medicine residency, it is no surprise that 1,500 medical students are needed to find a single future rheumatology fellow. Rheumatology is the best kept secret.
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