Adult Rheumatology Fellowship Program

Fellowship Title:

Adult Rheumatology Fellowship Program

Division:

Rheumatology

Fellowship Type:

Clinical and Research

Fellowship Director:

Dr. Vinod Chandran

Primary Supervisor:

Dr. Dana Jerome

Description:

Brief Description of the Fellowship Program

The Rheumatology fellowship mirrors the training program for our Royal College stream rheumatology PGY4s and PGY5s.  The IFTs have the same clinical and research experiences as our Royal College trainees. The PGY4 and 5 years in rheumatology are described in detail below.  There is a mixture of ambulatory and in-patient consult rotations that have graduated responsibility over the course of the two-year fellowship program.  The PGY4 year is comprised of mandatory rotations meant largely to build a strong general rheumatology foundation.  The PGY 5 year offers trainees some ability to customize their year based on their interest but mandates rotations in each of the main sub-specialty rheumatology areas, pediatric rheumatology and a community rotation.

Clinical or Clinical/Research Expectations of the Fellowship (% of time that is protected clinical time):

This is a clinical fellowship and outside of ½ day per week of research time, the remainder of the fellowship is clinical. The clinical experience for our PGY4’s and 5’s is graduated. In the PGY4 year the emphasis is on General Rheumatology and the acquisition of skills of the specialty, as well as familiarity with the more common rheumatic diseases. In the PGY5 year, the specialty clinics are attended with a view to learning more detail about rheumatic disease entities and extending the skills for detailed evaluation and follow-up. 1) Inpatient Ward: Toronto Western Hospital offers a unique opportunity for trainees to manage rheumatology inpatients directly in the capacity of a “junior staff person”, rounding with residents and teaching them, while at the same time having the supervisory backing of an attending staff rheumatologist.  2) Inpatient Consultation Service: At UHN, the consultation service at Toronto Western Hospital is combined with the inpatient ward service at Toronto Western Hospital. This consists of four elective beds on ward 4B Fell as well as emergency admissions under the Rheumatology service. The remainder of the consultations are done by a second team covering Mount Sinai Hospital in-patients, emergency and ICU, Toronto General Hospital in-patients, emergency and ICU, and Princess Margaret Hospital in-patients. PGY4’s also rotate through St. Michael’s Hospital and Sunnybrook Health Sciences Centre, each of which offers a different type of inpatient consultation experience. In-patients on the consultation services cover the whole spectrum from gout and osteoarthritic knees to pulmonary hemorrhage from ANCA associated vasculitis and organic brain syndrome from Lupus Cerebritis. In all cases the PGY4 takes a supervisory role, working with core internal medicine trainees from the PGY2 and PGY3 levels, doing many cases hands on as well. 3) General Rheumatology Clinics: All participating hospitals offer general rheumatology clinics with opportunity for trainees to work up new and follow-up cases, dictate consultation notes and arrange follow-up under the supervision of teaching staff. All cases are reviewed, dictations are often reviewed with trainees, and teaching occurs during the clinics. Physical examination techniques are observed and Residents have an opportunity to review case synthesis and treatment plan with staff. Joint injections are taught and supervised as part and parcel of this inpatient and clinical consultation experience. General rheumatology is also offered in community clinics, and each resident, gets a community experience somewhere in the Greater Toronto Area (in either their PGY4 or PGY5 year). 4) Specialty Clinics: PGY5 trainees are able to learn rheumatology in greater depth through subspecialty clinics in Ankylosing Spondylitis, Rheumatoid Arthritis, Scleroderma, Systemic Lupus Erythematosus, Psoriatic Arthritis, Vasculitis and Sjogren’s Syndrome. In these clinics residents consider measures of disease activity, radiological and clinical measures of disease damage and construct of clinical research cohorts. These clinics encourage a deeper understanding, greater familiarity and more intense academic curiosity about rheumatic diseases. They have opportunity for intense clinical experience in each of these areas, as well as opportunity to participate in research as per their choosing, fill in research protocols, learn about newer and upcoming therapies, discuss the ethics of clinical trials and take responsibility for management of these complicated cases. All Residents in the PGY5 year also have longitudinal clinics where they follow their own patients for a year. They play a junior staff role as first back-up for call after hours, and they participate in teaching. The PGY4 and PGY5 rotations are reinforced with teaching rounds, half day back, journal clubs and special seminars. 5) Special Opportunities: Opportunities exist university hospital wide for experience with other specialties as requested by the Resident in the PGY5 year. Residents have been given rotations in the past with osteoporosis clinics, sports medicine and nerve conduction and EMG testing. In addition, there are opportunities to work with other specialties in our clinics. The Sjogren’s Clinic is an integrated clinic with ENT, Ophthalmology and dentistry with regular meetings and interdisciplinary discussions. We have a combined clinic with nephrology for patients with Lupus Nephritis, and there has been a combined clinic with hematology for treatment of patients with antiphospholipid antibody syndrome. The Spondyloarthritis Clinic is run with a physiotherapist in attendance. Other opportunities include Pulmonary Hypertension Clinic, Dermatology/Rheumatology Combined Clinic. These latter clinics are multidisciplinary as well, and offer opportunities for collaboration and cross-specialty learning.

Research expectations of the fellowship (% of time that is protected research time):

Research and other scholarly activities are mandatory. Resident gets some time longitudinally over the year in the PGY4 and 5 year.  This is ½ day per week in most cases.  In some cases this could be more but would never exceed a total of 4 months over the course of a two year fellowship period. Residents have an orientation session during the first few months of their PGY4 year where they are introduced to the idea and requirements of a scholarly project.  This is a formal session where students are provided with an overview of requirements, examples of types of projects and some suggested time lines.  Students are provided with a list of University of Toronto faculty, their scholarly area of interest as well as a list of their ongoing projects.  Contact information is also included.  The PGY 4 trainees are asked to submit a proposal for their research project after the first 3-4 months of their training which has been signed off by their selected supervisor.  This project can be related to basic or epidemiologic research, Patient Quality and Safety, Education of some other area of scholarly pursuit.  These projects are submitted to and reviewed by the University of Toronto Rheumatology research committee and the trainees are provided with feedback to ensure that their project is achievable and well-conceived. Regular guidance is provided by preceptor and resident meets with Program Director and Division Director together later in year to discuss progress and problems. A progress sheet is maintained by the resident to identify status of research. Program provides a statistician to advise regarding research plan and assist in data analysis. Research is presented at an annual academic day (“Ogryzlo Day”) as well at ACR and CRA Annual Scientific Meetings. This is done under supervision and is an educational exercise.

Other expectations that the trainees are required to partake in/completed while in the fellowship (ie. rounds, presentations, research, call, etc…):

(1) Teaching: During the first few months of the PGY4 year, students receive a teaching session on “how to teach”. This includes some teaching theory as well as practical physical examination teaching where the trainees are observed in a teaching role and given real time feedback by faculty members. With these skills our trainees are asked to provide teaching to junior trainees when on either an in-patient service, consultation service or out-patient rotation.  Junior trainees are generally medical students, internal medicine residents or off-service trainees such as from physical medicine and rehab or family practice.  This teaching is sometimes informal but on certain rotations is also formal with organized teaching sessions in a classroom type setting. There are a lot of opportunities for teaching undergraduate clinical skills as well. This is not a requirement of the program but it is an opportunity offered to trainees who are interested.  If a student does wish to participate in teaching of undergraduate medicine, they are paired with a staff member who can guide them through the requirements, observe their teaching and provide feedback.  (2) Case presentation: Students are required to present to each other during our academic half day “case based learning” discussion. (3) Journal Club/rounds: students also present at journal club once per year and are involved in presentations at rheumatology intra-city rounds.  (4) On Call: Trainees are also “on call” to the emergency department and consultation services.  This is a rotating schedule and is generally 1 evening or weekend day of call per week.

Educational opportunities offered to fellows within the program (i.e. local, national, etc…):

Our trainees have a ½ day per week of protected educational time.  This is held on Friday afternoons and runs from 8am to 12 pm.  There is a pre-specified two-year curriculum of topics that are covered over this period of time.  A variety of teaching methods are used including case based discussions, didactic teaching and small group teaching.  The topics covered over the two-year period help ensure that all Royal College Objectives are covered over the course of the two-year training program.  Every 4 months there is an exam that the students take to evaluate them on the material covered in the preceding months. We also run, in addition to our academic half day, an immunology course.  This is a 12-week course taught by rheumatology faculty that covers the basics of immunology and the clinical application of this material.  There is an immunology exam at the completion of this course. Our trainees also participate in the Patient Quality and Safety Course offered through the Department of Medicine.  This provides them with training in Quality and Safety and together, in the PGY5 year, they complete a Quality project to be presented at the end of the PGY5 year.  The American College of Rheumatology provides a Fellowship in Training grant to pay for travel to and registration for the annual scientific meeting in the United States. The Canadian Rheumatology Association pays for travel, accommodation and registration at their Annual Conference. Residents are encouraged to prepare their research for presentation at these conferences. The Ontario Rheumatology Association sponsors an Ontario Rheumatology Resident’s weekend in Toronto yearly. In addition, a National Rheumatology Resident’s Weekend is held every two years, usually in Ottawa. These latter two events are more for the purpose of resident education, formative OSCE examinations and establishment of resident cohesiveness and morale.

Outline the scholarly expectations to be undertaken within the fellowship:

As per the Royal College requirements, our trainees are expected to complete a scholarly project.  The details of this were previously set out under the research section and this is repeated here. Research and other scholarly activities are mandatory. Resident gets some time longitudinally over the year in the PGY4 and PGY5 years.  This is ½ day per week in most cases. Residents have an orientation session during the first few months of their PGY4 year where they are introduced to the idea and requirements of a scholarly project.  This is a formal session where students are provided with an overview of requirements, examples of types of projects and some suggested time lines.  Students are provided with a list of University of Toronto faculty, their scholarly area of interest as well as a list of their ongoing projects.  Contact information is also included.  The PGY 4 trainees are asked to submit a proposal for their research project after the first 3-4 months of their training which has been signed off by their selected supervisor.  This project can be related to basic or epidemiologic research, quality, Education of some other area of scholarly pursuit.  These projects are submitted to and reviewed by the University of Toronto Rheumatology research committee and the trainees are provided with feedback to ensure that their project is achievable and well-conceived. Regular guidance is provided by preceptor and resident meets with Program Director and Division Director together later in year to discuss progress and problems. A progress sheet is maintained by the resident to identify status of research. Program provides a statistician to advise regarding research plan and assist in data analysis. Research is presented at an annual academic day (“Ogryzlo Day”) as well at ACR and CRA Annual Scientific Meetings. This is done under supervision and is an educational exercise.

Assessments:

The program uses a web-based evaluation system, POWER. The supervisors and residents receive the objectives at the beginning of each rotation.  A documented assessment of resident performance is completed at the end of every rotation, with mid-rotation feedback occurring at or around the midpoint of every rotation. Residents indicate on-line whether evaluations have been discussed when receiving the ITER. The Program Director supervises these looking for any trends of omission by staff.  Other types of evaluations are: ITERs, NWRITE exam, intermittent quizzes, OSCEs, Case Logs, Clinic evaluations, presentations, scholarly project evaluation. Marks are provided after all quizzes and NWRITE exams along with discussion of answers. OSCE evaluations are followed by feedback on an individual and group basisPGY4 trainees meet with Program Director three times in year, PGY5 trainees meet with program director twice in year to discuss progress, ITER’s, program committee evaluation, career planning.