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Rheumatology training at internal medicine and family practice residency programs.

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47 1
SPECIAL ARTICLE
RHEUMATOLOGY TRAINING AT
INTERNAL MEDICINE AND FAMILY PRACTICE
RESIDENCY PROGRAMS
DON L . GOLDENBERG, RAPHAEL J. DEHORATIUS, STEPHEN R. KAPLAN, JOHN MASON,
ROBERT MEENAN, SUSAN G. PERLMAN, and JOHN B. WINFIELD
The Medical Research Education Subcommittee
of the American Rheumatism Association surveyed a
random selection of large and small programs in internal medicine and family practice residency programs in
order to evaluate their rheumatology training. Formal
rheumatology training is offered in 90% of these residency programs, but many available positions are not
being filled. A full-time staff rheumatologist was present
at 69% of large internal medicine programs, 32% of
small internal medicine programs, and 11% of family
practice programs. The methods of rheumatology training are similar in most programs, although small internal medicine programs and family practice programs
more often utilize physicians’ offices or outside medical
centers for the rheumatology elective training. A majority of the directors of these residency programs thought
Don L. Goldenberg, MD: Chairman, American Rheumatism Association Medical Research Education Subcommittee, Associate Professor of Medicine, Clinical Program Director, Arthritis
Center, Boston University School of Medicine, Boston, Massachusetts; Raphael J. DeHoratius, MD: Professor of Medicine, Director,
Division of Clinical Immunology/Rheumatology, Hahnemann University, Philadelphia, Pennsylvania; Stephen R. Kaplan, MD: Professor of Medicine, Brown University Program in Medicine, Providence, Rhode Island; John Mason, MA: Medical Sociologist,
Research Associate, Arthritis Center, Boston University School of
Medicine; Robert Meenan, MD: Associate Professor of Medicine,
Associate Director, Multipurpose Arthritis Center, Boston University School of Medicine; Susan G. Perlman, MD: Assistant Professor of Clinical Medicine, Section of Arthritis and Connective Tissue
Diseases, Department of Medicine, Northwestern University, Chicago, Illinois; John B . Winfield, MD: Chairman, American Rheumatism Association Education Committee, Professor of Medicine,
Director, Multipurpose Arthritis Center, University of North Caroh a School of Medicine, Chapel Hill.
Address reprint requests to Don L. Goldenberg, MD,
Boston University School of Medicine, Arthritis Center, K5, 71
East Concord Street, Boston, MA 021 18.
Submitted for publication June 21, 1984; accepted in revised form October 23. 1984.
Arthritis and Rheumatism, Vol. 28, No. 4 (April 1985)
that many basic skills and techniques were not taught
adequately and that the training of their rheumatology
residents was not equal to that of residents in cardiology
or gastroenterology.
Rheumatic diseases affect about 10% of the
population (1). Five to ten percent of office visits to
general physicians are related to musculoskeletal
problems (2), and a small minority of these patients
will be referred to physicians with specialized training
in these disorders (3). The National Arthritis Plan
suggested that every primary and family physician be
trained in the diagnosis and treatment of the common
musculoskeletal conditions (4). Rheumatology training
of generalists occurs to a limited extent in medical
school (9, but it is likely that the most intensive
training in rheumatology occurs during residencies in
internal medicine and family practice. Little is known,
however, about the content or process of training in
rheumatic diseases at this critical stage of medical
education (6-8). Thus, the Medical Education Research Subcommittee of the American Rheumatism
Association (ARA) designed and conducted a survey
to evaluate the current status of rheumatology education in internal medicine and family practice programs
in the United States. The results of this survey provide
an overview of house staff training in rheumatology
and support conclusions about the general physician’s
education in rheumatology in the United States.
METHODS
Seven committee members designed the questionnaire to determine basic information regarding rheumatology
education. “Rheumatology was not defined in any descriptive fashion, although aspects of rheumatology training that
”
GOLDENBERG ET AL
472
the committee believed to be important were indirectly
conveyed to the respondents. These were specified in a
question about the level of training in the following areas of
rheumatology: musculoskeletal examination, differential diagnosis of acute arthritis, differential diagnosis of rheumatoid arthritis, management of rheumatoid arthritis, laboratory tests in the rheumatic diseases, synovial fluid analysis,
joint aspiration technique, diagnosis and management of
tendinitis, general principles of occupational and physical
therapy, and psychosocial aspects of chronic disease. The
respondents were asked to rate the level of training (good,
fair, poor) in each of these areas, and were asked to compare
the training of their residents in rheumatology with the
training of residents in other medical subspecialty areas such
as cardiology or gastroenterology.
Program variables were surveyed by questions that
could be answered by yes, no, or a numeric value. These
questions included: the total number of residents in the
program, the total number of residents in a rheumatology
elective each year, the percentage of available rheumatology
elective slots filled each year, the duration of rheumatology
training, specific assignments during the rheumatology training, including inpatient and outpatient consultations and
longitudinal care, private office experiences, rheumatology
attending rounds, teaching conferences, and orthopedic
training. Furthermore, the availability of other electives in
orthopedics, physical and rehabilitation medicine, gerontology, cardiology, pulmonary medicine, gastroenterology,
nephrology, oncology, hematology, endocrinology, and infectious diseases was surveyed. A description of the training
program, including medical school affiliation and faculty
rheumatologists, was provided. The specific weekly activities of rheumatology faculty in the following areas were also
determined: house officer teaching conferences, inpatient
consultations, hospital-based clinic, hospital-based clinical
and basic research, and general medical attending responsibilities.
The 1,125 internal medicine and family practice
programs listed in the 1982-1983 Directory of Residency
Programs (9) were initially grouped by the following variables: (a) internal medicine or family practice; (b) large or
small (small was defined as fewer than 30 residents; large
was defined as equal to or greater than 30 residents total in
each residency program); (c) general geographic location.
Since there were not many large family practice programs,
we later grouped all family practice programs into 1 category
and compared them with large internal medicine and small
internal medicine programs. Two hundred twenty-four programs were randomly selected to receive the questionnaire.
Completed questionnaires were received from 177
programs, a 79% response rate. The questionnaires were
answered by the internal medicine or family practice director
at 80% of the programs, and the other questionnaires were
completed by the rheumatology program director or by an
associate director of the residency training program. The
number of respondents from the 3 general categories included: 61 large internal medicine programs (35%), 44 small
internal medicine programs (25%), and 72 family practice
programs (40%).
The survey data were analyzed by applying chisquare tests for nominal data or counts and analysis of
variance for continuous variables, to look for overall differences across the 3 program types. If a significant difference
was found, initial analysis was followed by explicit paired
comparisons using chi-square for counts and t-tests for
continuous data. All differences reported as significant displayed P values 5 0.01. This conservative significance level
was chosen rather than the more traditional 0.05 level, in
order to adjust for multiple comparisons.
RESULTS
General characteristics and faculty of the residency programs. The mean number of house officers in
all of the programs surveyed was 36, with a range of 3225. The mean number of internal medicine house
officers was 37, whereas the mean number of family
practice house officers was 18. Seventy-three percent
of the respondents reported that their program was a
major affiliate of a medical school, and another 23%
reported that their residency program had some affiliation with a medical school.
Eighty-three percent of the large internal medicine programs, 70% of the small internal medicine
programs, but only 13% of the family practice programs had a rheumatology department affiliated with
their residency program (Table 1). A full-time staff
rheumatologist was present at 69% of the large internal
medicine programs, 32% of the small internal medicine
programs, and 11% of the family practice programs.
Each family practice program with a full-time rheumatologist was directly affiliated with a major medical
center and an internal medicine training program.
Large internal medicine programs were more likely to
be affiliated with a rheumatology fellowship program
and have more than 2 full-time staff rheumatologists.
Overall, 65 residency programs (37% of those surveyed) did not have a full-time staff rheumatologist
and 20 (14%) did not have a full-time or a part-time
staff rheumatologist.
Table 1. Rheumatology faculty manpower
% of programs
Large
internal
medicine
(n
Rheumatology
department
Full-time staff
rheumatologist
>2 full-time staff
=
61)
Small
internal
medicine
Family
practice
(n
(n
=
44)
=
72)
83
70
13*
69*
32
I1
38*
9
6
rheumatologists
* Significant difference compared with other 2 programs (P< 0.01).
473
RHEUMATOLOGY TRAINING IN THE U.S.
The family practice and small internal medicine
programs without a full-time staff rheumatologist provided formal rheumatology education by employing a
part-time rheumatologist or by sending their residents
to training sites outside their own medical center.
Eighteen of the 20 programs that did not have a fulltime or part-time faculty rheumatologist were contacted by telephone in order to determine who provided
rheumatology education to their residents. Ten of
these programs sent their residents to an affiliated
medical center that did have a staff rheumatologist and
an existing rheumatology training program. Five of the
18 programs sent their residents to the private practice
of a rheumatologist or an ipternist. Three of the 18
programs reported that they provided no formal staffsupervised rheumatology training.
The weekly teaching activities of the staff rheumatologists at large internal medicine programs more
often included inpatient consultations, didactic teaching conferences, and arthritis clinics, when compared
with the teaching activities of rheumatologists at small
internal medicine and at family practice programs
(Table 2). Less than 20% of the rheumatologists affiliated with family practice and small internal medicine
programs participated in weekly clinical or basic research, whereas approximately 70% of rheumatologists at large internal medicine programs were involved in these investigative activities (Table 2).
Content of rheumatology residency education.
Formal training in rheumatology was available at 92%
of all programs surveyed, including 93% of the internal
medicine programs and 90% of the family practice
programs. Three-fourths of the trainees received their
formal rheumatology education during a 1- or 2-month
elective. Most respondents reported that their programs provided a balance of inpatiept and ambulatory
Table 2. Weekly activities of staff rheumatologists*
Teaching conferences
inpatient consultations
Arthritis clinic
(hospital-based)
Clinical research
Basic research
Attending rounds
Large
internal
medicine
programs
(n = 61)
Small
internal
medicine
programs
(n = 44)
Family
practice
programs
(n = 72)
78t
95
89t
49
88
58
52
68t
38
76t
66t
84
20
17
63
16
16
49t
* % who participate in each of these activities weekly.
t Significant difference compared with other 2 programs (P< 0.01).
patient training experience, although the family practice programs were more likely to provide only ambulatory training.
During any single academic year, approximately one-quarter of residents at large internal medicine.
small internal medicine, and family practice programs
received some formal rheumatology education. In
contrast, the mean percentage of house officers who
received an orthopedic elective each year was 45% of
residents at family practice program$, 9% at small
internal medicine programs, and 4% at large internal
medicine programs. Whereas more than 75% of available rheumatology elective positions were filled by
residents at more than three-quarters of the large internal medicine programs, only about one-third of the small
internal medicine and one-quarter of the family practice
programs had filled more than 75% of their available
elective positions (Table 3). In contrast, fewer than onequarter of available elective positions were filled at 8%
of large internal medicine programs, and at 42% of
family practice programs.
The specific content of formal rheumatology
training at most programs included teaching conferences, inpatient consultations, and attending rounds
and ambulatory clinics (Table 4). Compared with the
large internal medicine programs, family practice residency programs and small internal medicine programs
more often provided some training in a private practice
office setting. Family practice programs more often
provided specific orthopedic training within their rheumatology elective in comparison with the internal
medicine programs, while large internal medicine programs more commonly presented weekly teaching
conferences.
Perceived training quality. Quality of training in
10 specific educational variables was assessed by the
program directors (Table 5). Approximately two-thirds
of program directors at all residency programs surveyed considered the training of their residents in the
Table 3. Percentage of available rheumatology elective positions
filled
% of programs
<25%
25-5096
50-75%
>75%
Large internal
medicine
(n = 61)
Small internal
medicine
(n = 44)
Family practice
(n = 72)
8
2
11
79*
18
24
20
38
42
22
9
27
* Significant difference compared with other 2 programs (P< 0.01).
GOLDENBERG ET AL
474
Table 4.
large and small internal medicine programs, more
often believed that their residents’ training in the
diagnosis and management of tendinitis and the psychosocial aspects of chronic disease was adequate. In
general, however, there were significant inadequacies
perceived with regard to each important training variable assessed. This perception of inadequacy was
especially striking with regard to the basic techniques
of a musculoskeletal examination and joint aspiration.
The program directors also were asked to assess the perceived adequacy of their rheumatology
training programs relative to that of cardiology and
gastroenterology. Only 10% of respondents reported
that the training received in rheumatology was slightly
or much better than that received in cardiology and
gastroenterology, whereas 39% of the respondents
believed the rheumatology training was slightly or
much worse than cardiology and gastroenterology
training. When program directors were asked what
they considered to be the single most important
change in current rheumatology training that would
help to improve the rheumatology skills of their residents, 40% of the respondents stated that exposure to
more patients with arthritis was most important, 25%
believed more general interest in rheumatology
throughout the residency program was most important, 19% thought that more emphasis on ambulatory
rheumatology was most important, and only 15%
stated that a larger rheumatology faculty was most
important.
Rheumatology elective curriculum
% of programs offering training
variable
Training variable
Large
internal
medicine
(n = 61)
Small
internal
medicine
(n = 44)
Family
practice
(n = 72)
Teaching conferences
Inpatient consultations
Attending rounds
Outpatient clinics
Emergency room
Private office
Orthopedics
98*
97
93
95
48
42*
42
81
97
86
86
50
67
19
83
89
80
90
35
78
54
* Significant difference compared with other 2 programs (P< 0.01).
general principles of occupational and physical therapy and the psychosocial aspects of chronic disease to
be inadequate. However, there were significant differences in the inadequacies perceived by the program
directors relative to the type and size of the program.
For example, a significantly greater number of directors at family practice and small internal medicine
programs, in comparison with those at large internal
medicine programs, considered their residents’ training inadequate in the interpretation of laboratory tests,
performance and interpretation of synovial fluid
analysis, and the technique of joint aspiration
(Table 5). In contrast, the family practice program
directors, in comparison with the directors of the
Table 5.
Perceived “inadequacies” of rheumatolow house officer training*
% of respondents who rated skill inadequate
Specific training variable
Musculoskeletal examination
Differential diagnosis of acute
arthritis
Differential diagnosis of rheumatoid
arthritis
Management of rheumatoid arthritis
Laboratory tests in the
rheumatic diseases
Synovial fluid analysis
Joint aspiration technique
Diagnosis and management
of tendinitis
General priniciples of occupational and
physical therapy
Psychosocial aspects of chronic
disease
Large internal
Small internal
medicine programs medicine programs
(n = 44)
(n = 61)
Family practice
programs
(n = 72)
33
12
50
23
39
31
12
23
31
25
15t
30
34
43
46
25t
33t
53
55
52
57
70
61
33t
76
82
68
61
73
41t
* For each training variable listed, the program directors rated their residents’ education as good, fair,
or poor. “Inadequate” represents the sum of fair and poor responses for each variable.
t Significant difference compared with other 2 programs ( P < 0.01).
RHEUMATOLOGY TRAINING IN THE U.S.
DISCUSSION
After evaluating rheumatology education in
U.S. medical schools, the Undergraduate Education
Subcommittee of the Education Committee of the
ARA reported that 10% of medical schools provided
no formal rheumatology education and that 13% did
not have a rheumatologist on their full-time faculty (5).
Furthermore, 22% of the schools did not have a
rheumatology fellowship program and 38% had 2 or
fewer full-time rheumatologists. Only 62% of the
schools provided specific training in musculoskeletal
examination. An intense 1- or 2-month rheumatology
elective was available to students at most medical
schools, but fewer than 20% of the medical students
participated in such electives. Three-fourths of the
rheumatology program directors at the medical
schools believed the educational impact of rheumatology on students was inadequate, primarily because of
a lack of significant exposure to rheumatology patients.
The current study, the first to evaluate the
rheumatology training of residents in internal medicine
and family practice programs throughout the United
States, found similar educational deficiencies. While
some formal rheumatology education is offered in 90%
of these residency programs, the availability, utilization, and content of this education varies significantly
with specific program characteristics. Those family
practice and small internal medicine programs without
a full-time staff rheumatologist (Table 1) utilized parttime rheumatologists or sent their residents to other
programs for formal rheumatology education. Since
formal training in rheumatology is not required, only
about one-quarter of residents each year participate, a
situation analogous to that in medical student rheumatology education (5). Whereas there are far too few
elective positions available in rheumatology at U. S.
medical schools (3,there is an underutilization of
available electives in rheumatology at the level of
residency training, especially in family practice and
small internal medicine programs (Table 3 ) .
Furthermore, residents were often considered
by program directors to be inadequately trained in the
techniques of musculoskeletal examination, synovial
fluid analysis, and joint aspiration. Ambulatory-oriented skills, such as the diagnosis and management of
tendinitis and the psychosocial aspects of chronic
disease, were more often judged to be inadequately
taught in the internal medicine programs, whereas the
interpretation of laboratory tests and synovial fluid
analysis were more often judged to be inadequately
taught in the family practice programs. In general, the
475
program directors believed their residents were not as
well trained in rheumatology as they were in cardiology or gastroenterology.
These perceived inadequacies may correlate
with the inefficient utilization of available elective
training positions in rheumatology. Recent studies
have concluded that a formal educational program in
rheuniatology is important if basic skills are to be
acquired during residency training (6-8). In contrast,
significant education may be acquired by “osmosis”
in medical subspecialties such as cardiology and gastroenterology, which are emphasized during general
inpatient medical training. Rheumatology training
skills, including a familiarity with many common musculoskeletal conditions such as soft tissue rheumatism
and osteoarthritis, can best be provided in ambulatory
sites over a long time frame. Therefore, residency
programs should focus greater emphasis on ambulatory rheumatology training. The Internal Medicine
Residency Review Committee recommends that
“most rotations on subspecialties should be at least six
weeks duration (9).” However, a 6-week rotation may
not be optimal or practical in the provision of basic
rheumatology training to most internal medicine residents.
The Family Practice Residency Review Committee recommends that the curriculum in internal
medicine should include both inpatient and outpatient
experiences in medical subspecialties and that the
faculty should include both general internists and
subspecialists (9). In contrast, 160-200 hours of orthopedic training is required. Thus, formal training in
orthopedics is provided for all family practice residents, and in a much greater degree than comparable
rheumatology training. The family practice residents
may receive substantial education in certain rheumatic
conditions during their orthopedic training, although
the content of this training is not known.
The validity of the information gathered by this
survey is subject to the accuracy of the program
directors’ responses. Formal validity testing is not
possible in such a survey. However, certain features
of the questionnaire design and analysis should have
served to increase validity. For example, most questions offered clear-cut dichotomous choices. The fact
that our analyses focused on comparisons of program
types, e.g., family practice versus internal medicine,
tends to balance inaccuracies and reduce threats to
validity. Furthermore, we are now in the process of
followup site visits to a sample of the responding
programs. These site visits will validate the reliability
of the program directors’ responses and, more importantly, will provide an instrument to evaluate the
GOLDENBERG ET AL
476
impact of these rheumatology training variables on
residents’ performance.
In conclusion, our survey of residency training
at family practice and internal medicine programs
found that formal training in rheumatology is offered at
the great majority of programs throughout the United
States, although currently the available educational
positions are not fully utilized. Program directors
thought that the rheumatology education of their trainees was not adequate in regard to a number of specific
variables, and that they would benefit from greater
exposure to rheumatology and a greater mastery of
basic rheumatology skills.
REFERENCES
1. Bennett PH, Wood PHN: Population Studies of the
Rheumatic Diseases. Amsterdam, Excerpta Medica, 1968
2. DeLozier JE, Gagnon RO: National Ambulatory Medical
Care Survey. DHEW Publication No. 761772. Rockville,
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Maryland, US Department of Health, Education and
Welfare, 1975
Ogryzlo MA: Editorial: specialty of rheumatology-manpower requirements. J Rheumatol 2: 1-4, 1975
Engleman EP: The National Arthritis Plan: an overview.
Arthritis Rheum 20: 1-6, 1977
Goldenberg DL, Mason JH, DeHoratius R, Goldberg V ,
Kaplan SR, Keiser H , Lockshin MD, Rynes R, Sandson
JI, Schumacher HR, Skosey J: Rheumatology education
in United States medical schools. Arthritis Rheum
24:1561-1566, 1981
Goldenberg DL, Meenan RF, Allaire S, Cohen AS: The
educational impact of a rheumatology elective. Arthritis
Rheum 26:658-663, 1983
Eyanson S , Brandt KD: Some effects on houseofficers of
an elective rheumatology rotation. J Rheumatol 7:25 1257, 1980
Strosberg MA, Strosberg JM: Do family practice residents in the United States learn clinical rheumatology?
An important question. J Rheumatol7:923-926, 1980
1982-1983 Directory of Residency Training Programs.
Chicago, American Medical Association, 1982
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