An Online Program for Primary Care Practitioners to Enhance Confidence in Ability to Care for Patients With or at Risk of Painful Knee Osteoarthritis.

OBJECTIVE: Primary care practitioners (PCPs) care for the majority of patients with knee osteoarthritis (KOA). Despite the existing evidence-based guidelines, PCPs often feel unequipped to evaluate and effectively treat patients with KOA. To address this need, we designed and implemented a free internet-based program focusing on the diagnosis and treatment of KOA. We assessed whether the program led to improvements in participants' confidence in their knowledge and skills related to effectively recognizing and caring for patients with or at risk of KOA. METHODS: We used Caffarella's integrative model to develop a program aligned with the American College of Rheumatology 2019 Guideline for the treatment of KOA. The program incorporated 18 case-based questions to provide retrieval practice and mastery experiences. We assessed changes in participants' confidence in their KOA knowledge and skills after program completion. RESULTS: Of the first 353 learners completing the program, 53.8% were women, 41.9% had a clinical focus in primary care, and 69.1% were nonphysicians. Overall confidence in KOA knowledge and skills improved after program completion (P < 0.001; effect size = 1.28, 95% confidence interval 1.12-1.45), with largest improvements among participants with lower pre-program confidence. A total of 95.8% of participants indicated they would recommend the program to others. CONCLUSION: A free online program focusing on the effective care for patients with KOA attracted a wide range of learners, even though it targeted PCPs. Participants overwhelmingly endorsed it as highly relevant and would recommend it to others. Whether improvements in confidence translate into better patient outcomes is an important area for future research.

An Instrument for Measuring Critical Appraisal Self-Efficacy in Rheumatology Trainees.

OBJECTIVE: Self-efficacy, the internal belief that one can perform a specific task successfully, influences behavior. To promote critical appraisal of medical literature, rheumatology training programs should foster both competence and self-efficacy for critical appraisal. This study aimed to investigate whether select items from the Clinical Research Appraisal Inventory (CRAI), an instrument measuring clinical research self-efficacy, could be used to measure critical appraisal self-efficacy (CASE). METHODS: One hundred twenty-five trainees from 33 rheumatology programs were sent a questionnaire that included two sections of the CRAI. Six CRAI items relevant to CASE were identified a priori; responses generated a CASE score (total score range 0-10; higher = greater confidence in one's ability to perform a specific task successfully). CASE scores' internal structure and relation to domain-concordant variables were analyzed. RESULTS: Questionnaires were completed by 112 of 125 (89.6%) trainees. CASE scores ranged from 0.5 to 8.2. The six CRAI items contributing to the CASE score demonstrated high internal consistency (Cronbach's α = 0.95) and unidimensionality. Criterion validity was supported by the findings that participants with higher CASE scores rated their epidemiology and biostatistics understanding higher than that of peers (P < 0.0001) and were more likely to report referring to studies to answer clinical questions (odds ratio 2.47, 95% confidence interval 1.41-4.33; P = 0.002). The correlation of CASE scores with percentage of questions answered correctly was only moderate, supporting discriminant validity. CONCLUSION: The six-item CASE instrument demonstrated content validity, internal consistency, discriminative capability, and criterion validity, including correlation with self-reported behavior, supporting its potential as a useful measure of critical appraisal self-efficacy.

Using an experiential learning model to teach clinical reasoning theory and cognitive bias: an evaluation of a first-year medical student curriculum.

BACKGROUND: Most medical students entering clerkships have limited understanding of clinical reasoning concepts. The value of teaching theories of clinical reasoning and cognitive biases to first-year medical students is unknown. This study aimed to evaluate the value of explicitly teaching clinical reasoning theory and cognitive bias to first-year medical students. METHODS: Using Kolb's experiential learning model, we introduced dual process theory, script theory, and cognitive biases in teaching clinical reasoning to first-year medical students at an academic medical center in New York City between January and June 2020. Due to the COVID-19 pandemic, instruction was transitioned to a distance learning format in March 2020. The curriculum included a series of written clinical reasoning examinations with facilitated small group discussions. Written self-assessments prompted each student to reflect on the experience, draw conclusions about their clinical reasoning, and plan for future encounters involving clinical reasoning. We evaluated the value of the curriculum using mixed-methods to analyze faculty assessments, student self-assessment questionnaires, and an end-of-curriculum anonymous questionnaire eliciting student feedback. RESULTS: Among 318 total examinations of 106 students, 254 (80%) had a complete problem representation, while 199 (63%) of problem representations were considered concise. The most common cognitive biases described by students in their clinical reasoning were anchoring bias, availability bias, and premature closure. Four major themes emerged as valuable outcomes of the CREs as identified by students: (1) synthesis of medical knowledge; (2) enhanced ability to generate differential diagnoses; (3) development of self-efficacy related to clinical reasoning; (4) raised awareness of personal cognitive biases. CONCLUSIONS: We found that explicitly teaching clinical reasoning theory and cognitive biases using an experiential learning model provides first-year medical students with valuable opportunities for developing knowledge, skills, and self-efficacy related to clinical reasoning.

The Value of Supporting Education Research in the Academic Environment: The Hospital for Special Surgery Academy of Rheumatology Medical Educators.

PROBLEM: Medical education academies have been instrumental in providing greater recognition of and promotion for clinician-educators. However, producing education scholarship is essential for clinician-scholar-educator career advancement. Grant funding for education research and protected time to produce scholarship are still lacking for interested physicians, in part due to institutional budget constraints and competing priorities. APPROACH: The Hospital for Special Surgery Academy of Rheumatology Medical Educators was founded in 2011 to promote education scholarship through grants awarded to educators interested in research. Educators were asked to submit proposals aimed at the development of new teaching programs and curricular change. Selected applicants received up to $50,000 per year for one year. Grant money was obtained through directed fundraising from donors. Information from annual grant updates and survey responses from grant recipients in 2017 were used to assess the academy's effectiveness. OUTCOMES: Since 2012, 32 grants have been awarded, totaling $954,045 in funding. Recipients have produced national meeting abstracts, posters, oral presentations, and manuscripts and created unique curricula and electronic learning tools for medical students, residents, fellows, faculty, and patients. Four educators with demonstrated interest and research outcomes were identified during the pilot and received additional funding and support from a dedicated education research assistant. NEXT STEPS: The academy and the innovations grants program highlight the talents of under-supported and under-recognized teaching faculty by allowing them to distinguish themselves academically as clinician-scholar-educators. The success of these educators emphasizes the clear advantages of a formalized structure to achieve the hospital's education goals. Next steps include providing support for a rheumatology fellow to develop an education research career rather than one in bench, clinical, or translational research.

A Covid-19 Patient with Complement-Mediated Coagulopathy and Severe Thrombosis.

We report a patient with severe Covid-19-associated coagulopathy and type 2 diabetes mellitus who tested positive for antiphospholipid antibodies (aPL). Analysis of skin specimens suggested direct SARS-CoV-2 viral-induced and complement-mediated vascular injury and thrombosis, consistent with prior reports. Serial aPL testing demonstrated high levels of anticardiolipin antibodies (aCL) that declined to insignificant levels over a period of 5 weeks. SARS-CoV-2 RNA was detected in nasopharyngeal swab specimens on serial assays performed over the same 5-week period, though it was not detected thereafter. We hypothesize that SARS-CoV-2 viral-induced aPL contributed to severe Covid-19-associated coagulopathy in this patient.

Learning to Critically Appraise Rheumatic Disease Literature: Educational Opportunities During Training and into Practice.

To provide optimal patient care, rheumatologists must be equipped and motivated to critically appraise the literature. The conceptual frameworks Retrieval Enhanced Learning, Self-Determination Theory, and Communities of Practice can inform the design of educational approaches to promote critical appraisal in practice. HSS CLASS-Rheum® is a learning tool that can be used to help rheumatologists learn skills for critical appraisal through retrieval practice. Combining retrieval practice with opportunities for connection through Peer Instruction, journal clubs, and other forums can help support engagement and internalization of motivation, promoting persistence with critical appraisal in practice.

Rheumatology Research Foundation Clinician Scholar Educator Award: Fifteen Years Promoting Rheumatology Educators and Education.

OBJECTIVE: The Rheumatology Research Foundation's Clinician Scholar Educator (CSE) award is a 3-year career development award supporting medical education research while providing opportunities for mentorship and collaboration. Our objective was to document the individual and institutional impact of the award since its inception, as well as its promise to strengthen the subspecialty of rheumatology. METHODS: All 60 CSE Award recipients were surveyed periodically. Fifty-six of those 60 awardees (90%) responded to requests for survey information that included post-award activities, promotions, and further funding. Data were also collected from yearly written progress reports for each grant. RESULTS: Of the total CSE recipients to date, 48 of 60 (80%) are adult rheumatologists, 11 of 60 (18%) are pediatric rheumatologists, and 1 is an adult and pediatric rheumatologist. Two-thirds of survey respondents spend up to 30% of their total time in educational activities, and one-third spend greater than 30%. Thirty-one of the 60 CSE recipients (52%) have published a total of 86 medical education papers. Twenty-six of 52 (50%) had received an academic promotion following the award. Eleven awardees earned advanced degrees. CONCLUSION: We describe the creation and evolution of a grant program from a medical subspecialty society foundation and the impact on producing education research, individual identity formation, and ongoing support for educators. This community of rheumatology scholar educators now serves as an important resource at the national level for the American College of Rheumatology and its membership. We believe that this grant may serve as a model for other medical societies that want to promote education scholarship and leadership within their specialties.

Fellow use of medical jargon correlates inversely with patient and observer perceptions of professionalism: results of a rheumatology OSCE (ROSCE) using challenging patient scenarios.

The NYC Rheumatology Objective Structured Clinical Examination (NYC-ROSCE) is held annually to assess fellow competencies. We recently redesigned our OSCE to better assess subspecialty trainee communication skills and professionalism by developing scenarios in which the patients encountered were psychosocially or medically complex. The objective of this study is to identify which types of verbal and non-verbal skills are most important in the perception of professionalism in the patient-physician interaction. The 2012-2013 NYC-ROSCEs included a total of 53 fellows: 55 MD evaluators from 7 NYC rheumatology training programs (Hospital for Special Surgery-Weill Cornell (HSS), SUNY/Downstate, NYU, Einstein, Columbia, Mount Sinai, and North Shore/Long Island Jewish (NSLIJ)), and 55 professional actors/standardized patients participated in 5 stations. Quantitative fellow performance assessments were made on the following: maintaining composure; partnering with the patient; honesty; professionalism; empathy; and accountability. Free-text comments were solicited regarding specific strengths and weaknesses. A total of 53/53 eligible (100 %) fellows were evaluated. MD evaluators rated fellows lower for professionalism than did the standardized patients (6.8 ± 0.6 vs. 7.4 ± 0.8, p = 0.05), suggesting that physicians and patients view professionalism somewhat differently. Fellow self-evaluations for professionalism (6.6 ± 1.2) were concordant with those of the MD evaluators. Ratings of empathy by fellows themselves (6.6 ± 1.0), MD evaluators (6.6 ± 0.7), and standardized patients (6.6 ± 1.1) agreed closely. Jargon use, frequently cited by evaluators, showed a moderate association with lower professionalism ratings by both MD evaluators and patients. Psychosocially challenging patient encounters in the NYC-ROSCE permitted critical assessment of the patient-centered traits contributing to impressions of professionalism and indicate that limiting medical jargon is an important component of the competency of professionalism.

Fracture liaison services: promoting enhanced bone health care.

The high prevalence of osteoporotic fractures and their major effect on morbidity and mortality emphasizes the critical need to optimize bone health care. Patients presenting with fragility fractures are at high risk of subsequent fracture, but treatment rates have remained low for these patients. Recently developed fracture liaison services have successfully increased osteoporosis treatment, with improved patient outcomes. We review factors contributing to the treatment gap in osteoporosis, the function of fracture liaison services in reducing this gap, and lessons learned from the literature on effective formats, key elements, and suggestions for managing challenges in implementation of a fracture liaison service.

Building a rheumatology education academy: insights from assessment of needs during a rheumatology division retreat.

OBJECTIVE: To implement a rheumatology department education retreat to systematically identify and address the key factors necessary to improve medical education in our division in preparation for developing a rheumatology academy. METHODS: The Hospital for Special Surgery organized a retreat for the Rheumatology Department aimed at (1) providing formal didactics and (2) assessing participants' self-reported skills and interest in education with the goal of directing this information toward formalizing improvement. In a mixed-methods study design, faculty and fellows in the Division of Rheumatology were surveyed online pre- and post-retreat regarding various aspects of the current education program, their teaching abilities, interest and time spent in teaching, divisional resources allocated, and how education is valued. RESULTS: Enthusiasm for teaching was high before and rose further after the retreat. Confidence in abilities was higher than expected before but fell afterward. Many noted that the lack of specific feedback on teaching skills and useful metrics to assess performance prevented the achievement of educational excellence. Most responding felt lack of time, knowledge of how to teach well, and resources prevented them from making greater commitments to educational endeavors and participating fully and effectively in the department's teaching activities. CONCLUSION: While most rheumatology faculty members want to improve as teachers, they know neither where their educational strengths and weaknesses lie nor where or how to begin to change their teaching abilities. The key elements for an academy would thus be an educational environment that elevates the quality of teaching throughout the division and promotes teaching careers and education research, and raises the importance and quality of teaching to equivalence with clinical care and research.

Creating an academy of medical educators: how and where to start.

BACKGROUND: While most faculty members want to improve as teachers, they neither know where their educational strengths and weaknesses lie nor where or how to begin to effect a change in their teaching abilities. The lack of actionable, directed and specific feedback, and sensible and sensitive metrics to assess performance and improvement complicates the attainment of educational excellence. PURPOSE: The purpose of this article was to outline a series of specific steps that medical education programs can take to enhance the quality of teaching, promote teaching excellence, elevate the status and value of medical educators, and stimulate the creation of innovative teaching programs and curricula. METHODS: To achieve these goals at the Hospital for Special Surgery, the Academy of Rheumatology Medical Educators was formed. The academy had the following goals: (1) create within our institution a mission which advances and supports educators, (2) establish a membership composed of distinguished educators, (3) create a formal organizational structure with designated leadership, (4) dedicate resources that fund mission-related initiatives and research, and (5) establish a plan for promoting teachers as well as enhancing and advancing educational scholarship. RESULTS: The Hospital for Special Surgery Academy of Rheumatology Medical Educators was recently formed to address these goals by promoting teaching and learning of musculoskeletal skills in an environment that is supportive to educators and trainees and provides much needed resources for teachers. SUMMARY: The development of a pilot academy of medical educators represents one of the high-priority goals of those institutions that wish to elevate and enrich their teaching through a structured, proven approach.

Standardized patient outcomes trial (SPOT) in neurology.

BACKGROUND: The neurologic examination is a challenging component of the physical examination for medical students. In response, primarily based on expert consensus, medical schools have supplemented their curricula with standardized patient (SP) sessions that are focused on the neurologic examination. Hypothesis-driven quantitative data are needed to justify the further use of this resource-intensive educational modality, specifically regarding whether using SPs to teach the neurological examination effects a long-term benefit on the application of neurological examination skills. METHODS: This study is a cross-sectional analysis of prospectively collected data from medical students at Weill Cornell Medical College. The control group (n=129) received the standard curriculum. The intervention group (n=58) received the standard curriculum and an additional SP session focused on the neurologic examination during the second year of medical school. Student performance on the neurologic examination was assessed in the control and intervention groups via an OSCE administered during the fourth year of medical school. A Neurologic Physical Exam (NPE) score of 0.0 to 6.0 was calculated for each student based on a neurologic examination checklist completed by the SPs during the OSCE. Composite NPE scores in the control and intervention groups were compared with the unpaired t-test. RESULTS: In the fourth year OSCE, composite NPE scores in the intervention group (3.5±1.1) were statistically significantly greater than those in the control group (2.2±1.1) (p<0.0001). CONCLUSIONS: SP sessions are an effective tool for teaching the neurologic examination. We determined that a single, structured SP session conducted as an adjunct to our traditional lectures and small groups is associated with a statistically significant improvement in student performance measured 2 years after the session.

A pravastatin dose-escalation study in systemic lupus erythematosus.

Statin medications have been suggested for widespread use in patients with systemic lupus erythematosus (SLE). We studied the dose effectiveness and tolerability of pravastatin in SLE. We compared 41 SLE subjects in a two-month open-label dose-titration study of pravastatin to 22 SLE controls. Lipids, ALT, CPK, CRP, adverse effects were assessed. Linear mixed models assessed changes in lipids and CRP, comparing pravastatin subjects to controls. After 1 month of pravastatin 10 mg a day, total cholesterol decreased by 16% (+/-12.1%) and LDL by 24% (+/-17%), compared with 1.8% (+/-7.5%) and 2.6% (+/-8.6%) decreases in controls (P < 0.001). CRP did not decline. Glucocorticoids appeared to decrease pravastatin effectiveness. Serum CPK increased in one subject. Pravastatin reduced LDL and total cholesterol levels approximately the same degree observed in normal individuals, but the effect appeared blunted in those on modest doses of glucocorticoids and those with higher BMI.