Revisiting Race, Ethnicity, and Disparities in Rheumatology Educational Materials: An Update Since 2020.

OBJECTIVE: In 2020, one study by Strait and colleagues raised awareness that the clinical images in rheumatology educational materials underrepresent people with skin of color (P-SOC). Since then, publishers of rheumatology educational materials have focused on addressing this shortcoming. This study investigates the change in representation of P-SOC following the review of Strait et al. METHODS: We used the methods of the aforementioned study to collect images from commonly referenced rheumatology educational materials and categorized the skin tones within them as "light" or "dark." We calculated the proportional change in images depicting dark skin tones between 2020 and 2022 from the American College of Rheumatology (ACR) Image Library, the 10th edition of Kelley's Textbook of Rheumatology, and New England Journal of Medicine (NEJM) as well as between 2020 and 2024 from rheumatology articles within UpToDate. We compared results using one-sided Z-tests. RESULTS: Overall, the proportion of images depicting dark skin tones increased 40.6% (P < 0.0001). The 10th edition of Kelley's Textbook of Rheumatology most significantly increased inclusion of P-SOC (90.1%; P = 0.0039), with ACR Image Library, UpToDate, and NEJM also enhancing representation (41.9%, P < 0.0001; 31.0%, P = 0.0083; 28.2%, P = 0.3046, respectively). CONCLUSION: This study assesses the progress of rheumatology educational materials toward equitable representation of P-SOC. It demonstrates that awareness coupled with focused efforts from educational publishers can enhance the proportion of images depicting dark skin tones, thereby enriching the quality of foundational knowledge relayed to rheumatology providers with the goal of improving health experiences and outcomes for P-SOC with rheumatic diseases.

Shared Decision-Making During Virtual Care Regarding Rheumatologic and Chronic Conditions: Qualitative Study of Benefits, Pitfalls, and Optimization.

OBJECTIVE: Virtual care (VC) is an accepted modality of care delivery, and shared decision-making (SDM) benefits patients with rheumatologic and chronic conditions (RCCs). Unfortunately, research suggests reduced quality of SDM during VC. This study explores the benefits and shortcomings of SDM regarding RCCs during VC with suggestions for optimally using VC during SDM. METHODS: Following Stiggelbout's framework for SDM, we conducted focus groups of patients with RCCs and providers to understand their experiences with SDM during VC, probing for facilitating and challenging factors. We conducted content analysis of the transcripts, defining themes, and inductively reasoned to identify relationships among themes. We summarized the facilitators, barriers, and opportunities for improving SDM during VC that participants proposed. RESULTS: Virtual SDM shares several similarities with in-person practice, as both draw upon trusting patient-provider relationships, following the same general steps, and relying on effective communication. VC presents solutions for known barriers to in-person SDM, expanding time for making decisions and access to care. Technology and virtual health systems introduce new barriers to SDM, and participants list opportunities for overcoming these concerns. CONCLUSION: VC is a tool that can enhance and even support superior SDM compared with in-person visits when implemented successfully, a condition requiring the development of nuanced skills to correctly identify when and how to best use VC for SDM as well as technology and health care structures that integrate SDM into VC. Therefore, patients, providers, insurance carriers, and policy makers all contribute to the success of SDM among RCCs during VC.

Power of Representation in Educational Materials: Teaching Cutaneous Lupus Across Skin Tones in an Interactive Module.

OBJECTIVE: Clinicians report low confidence assessing cutaneous lupus erythematosus (CLE) lesions, especially for patients who identify as Black, Indigenous, and People of Color (BIPOC) who are historically excluded from educational materials. To address this, we created an online, interactive module teaching an approach to assessing CLE across skin tones and measured its impact on medical knowledge and confidence. METHODS: Our team created a module with case-based methods to introduce an approach to CLE, common mimicking rashes, and tips for photographing cutaneous lesions in BIPOC. Graduate medical trainees from five academic institutions completed the module. Using surveys and pre-post testing, we assessed changes in medical knowledge and clinical confidence along with learner satisfaction, comparing responses using Wilcoxon-signed rank tests and chi square analysis. We assessed the module's representation of light, medium, and dark skin tones with chi square analysis. RESULTS: The module represented light, medium, and dark skin tones (χ2 = 4.788, P = 0.091) among 102 images (77.5%, n = 79) were novel images from authors' personal libraries. Ninety-four participants completed the postmodule test and evaluation survey. Analyses revealed significant improvement in medical knowledge identifying serologic studies associated with subacute CLE (χ2 = 14.035, P < 0.001) and describing how to photograph rashes (χ2 = 38.211, P < 0.001). Participants reported improved confidence across all learning objectives after module completion (P < 0.001). CONCLUSION: This module is the first to introduce an approach to assessing CLE across skin tones, effectively increasing medical knowledge and confidence among graduate medical trainees.

Incorporating Telemedicine in Rheumatology Fellowship Training Programs: Needs Assessment, Curricular Intervention, and Evaluation.

OBJECTIVE: To increase the confidence of rheumatology fellows in training (FITs) in delivering virtual care (VC) and prepare them for independent practice, we developed educational materials addressing gaps in their skills. METHODS: We identified gaps in telemedicine skills based on FIT performance in a virtual rheumatology objective structured clinical examination (vROSCE) station on VC delivery using video teleconference technology and survey (survey 1) responses. We created educational materials including videos of "mediocre" and "excellent" VC examples, discussion/reflection questions, and a document summarizing key practices. We measured change in the confidence levels of FITs for delivering VC with a post-intervention survey (survey 2). RESULTS: Thirty-seven FITs (19 first-year, 18 second- plus third-year fellows) from 7 rheumatology fellowship training programs participated in a vROSCE and demonstrated gaps in skills mapping to several Rheumatology Telehealth Competency domains. Confidence levels of FITs improved significantly from survey 1 to survey 2 for 22 of 34 (65%) questions. All participating FITs found the educational materials helpful for learning and reflecting on their own VC practice; 18 FITs (64%) qualified usefulness as "moderately" or "a lot." Through surveying, 17 FITs (61%) reported implementing skills from the instructional videos into VC visits. CONCLUSION: Continually assessing our learners' needs and creating educational materials addressing gaps in training are requisite. Using a vROSCE station, needs assessments, and targeted learning with videos and discussion-guidance materials enhanced the confidence level of FITs in VC delivery. It is imperative to incorporate VC delivery into fellowship training program curricula to ensure breadth in skills, attitudes, and knowledge of new entrants into the rheumatology workforce.

Workshop, Assessment, and Validity Evidence for Tools Measuring Performance of Knee and Shoulder Arthrocentesis.

Introduction: Musculoskeletal concerns are common, yet residents at our institution lacked arthrocentesis training. We created a workshop to teach residents knee and shoulder arthrocentesis, developed simulated assessment scenarios (SASs) with tools to measure procedural proficiency, and collected validity evidence. Methods: A multidisciplinary group conducted a modified Delphi to define content for the workshop, SASs, and assessment tools. We defined minimum thresholds for competence in knee and shoulder arthrocentesis using the modified borderline-group method. We implemented the workshop and SASs in 2020 and 2021 and analyzed assessment tool scoring for statistical reliability and validity. Our program evaluation included SAS performance, participants' survey responses, and change in the number of arthrocenteses performed in the internal medicine (IM) resident primary care clinic. Results: Sixty-one residents (53 IM, eight physical medicine and rehabilitation [PM&R]) participated. Fifty-two (85%; 46 IM, six PM&R) completed the evaluation survey. We procured data from 48 knee and 65 shoulder SASs for validity evidence. All arthrocentesis SAS performances met the proficiency standard except one resident's shoulder SAS. Validity evidence revealed strong interrater reliability (α = .82 and .77 for knee and shoulder, respectively) and strong relational validity (p < .001 for both procedures). All participants rated workshop quality and usefulness as good or very good. The number of arthrocenteses performed at our institution's primary care clinic increased. Discussion: We created a workshop to teach residents arthrocentesis and assessment tools with strong validity and reliability evidence. The workshop was well regarded by residents, who applied their arthrocentesis skills during patient care.

Rethinking the Difficult Patient: Formative Qualitative Study Using Participatory Theater to Improve Physician-Patient Communication in Rheumatology.

BACKGROUND: Effective physician-patient communication is crucial for positive health outcomes for patients with chronic diseases. However, current methods of physician education in communication are often insufficient to help physicians understand how patients' actions are influenced by the contexts within which they live. An arts-based participatory theater approach can provide the necessary health equity framing to address this deficiency. OBJECTIVE: The aim of this study was to develop, pilot, and conduct a formative evaluation of an interactive arts-based communication skills intervention for graduate-level medical trainees grounded in a narrative representative of the experience of patients with systemic lupus erythematosus. METHODS: We hypothesized that the delivery of interactive communication modules through a participatory theater approach would lead to changes in both attitudes and the capacity to act on those attitudes among participants in 4 conceptual categories related to patient communication (understanding social determinants of health, expressing empathy, shared decision-making, and concordance). We developed a participatory, arts-based intervention to pilot this conceptual framework with the intended audience (rheumatology trainees). The intervention was delivered through routine educational conferences at a single institution. We conducted a formative evaluation by collecting qualitative focus group feedback to evaluate the implementation of the modules. RESULTS: Our formative data suggest that the participatory theater approach and the design of the modules added value to the participants' learning experience by facilitating interconnection of the 4 communication concepts (eg, participants were able to gain insight into both what physicians and patients were thinking about on the same topic). Participants also provided several suggestions for improving the intervention such as ensuring that the didactic material had more active engagement and considering additional ways to acknowledge real-world constraints (eg, limited time with patients) in implementing communication strategies. CONCLUSIONS: Our findings from this formative evaluation of communication modules suggest that participatory theater is an effective method for framing physician education with a health equity lens, although considerations in the realms of functional demands of health care providers and use of structural competency as a framing concept are needed. The integration of social and structural contexts into the delivery of this communication skills intervention may be important for the uptake of these skills by intervention participants. Participatory theater provided an opportunity for dynamic interactivity among participants and facilitated greater engagement with the communication module content.

Addressing Competency in Rheumatology Telehealth Care Delivery.

OBJECTIVE: Telehealth is an essential facet of care delivery for patients with rheumatic diseases. The Association of American Medical College's (AAMC) telehealth competencies (TCs) define the skills required for delivering general telehealth care across the range of clinician experience. In this study, the American College of Rheumatology's (ACR) TCs working group aimed to adapt the AAMC TCs to rheumatology, outlining the skills acquisition unique to rheumatology with a focus on knowledge, skills, and behaviors expected of recent rheumatology fellowship graduates. METHODS: Through a collaborative process, the working group adapted the AAMC TCs to the training structure and practice of rheumatology. The rheumatology TCs underwent peer review among recipients of the Clinician Scholar Educator Award and attendees at the ACR 2021 Convergence conference. RESULTS: The rheumatology TCs define 24 essential skills required for synchronous telehealth care of patients with rheumatic diseases. The working group adapted the AAMC's 20 TCs organized within 6 domains, added 2 skills to the AAMC's domains of patient safety and appropriate use, and data collection and assessment, and created a novel domain of systems-based requirements with 2 competencies. The rheumatology TCs define expected skill levels for recent rheumatology fellowship graduates and experienced rheumatology clinicians. CONCLUSION: The rheumatology TCs represent the first adaptation of the AAMC TCs to subspecialty care, expanding the scope to include rheumatology fellowship graduates and additional domains of rheumatology practice. These competencies can guide curricular innovations and measurements of proficiency in telehealth care delivery among rheumatology trainees and experienced clinicians, enhancing the care provided to patients with rheumatic diseases.

Representation of Skin Colors in Images of Patients With Lupus.

OBJECTIVE: Lupus presents earlier and more severely among patients with skin of color (SOC), and this population experiences worse outcomes. Providers rely on medical education materials when developing skills to care for patients, yet these resources historically underrepresent patients with SOC and marginalize vulnerable populations. In this study, we investigated if this publication bias extends to images depicting patients with lupus. METHODS: We reviewed published images of patients with lupus from rheumatology, dermatology, and internal medicine textbooks and medical journals, SOC atlases, online image libraries, UpToDate, and Google Images. We selected materials published from 2014 to 2019 that were available through our university's online medical library. We used the search terms "lupus" and "lupus rash" to identify images. We rated the skin color in each image using the New Immigrant Survey Skin Color Scale and categorized them as light, medium, or dark. We compared the frequencies of published skin tones with chi-square and odds ratio analyses. RESULTS: We assessed the skin tone of 1,417 images. The significant majority (56.4%) of the images represented light skin (χ2  = 490.14, P < 0.001). After SOC atlases, journals were the most inclusive of images depicting dark skin tones. The specialty of dermatology was most inclusive of medium and darker skin tones. CONCLUSION: Published images of lupus underrepresent patients with SOC, which may limit providers' ability to deliver care to the patients who are at greatest risk for complications.

Health care practitioners' confidence assessing lupus-related rashes in patients of color.

Background: Patients with skin of color (P-SOC) are disproportionately burdened by lupus and often have worse disease outcomes than white patients. This is partly because educational materials underrepresent P-SOC, thereby promoting unconscious bias and clinical deficiencies among practitioners.Purpose: We sought to measure providers' confidence in diagnosing the cutaneous manifestations of lupus (i.e., lupus-related rashes) in P-SOC and to assess which factors influenced their confidence.Research Design: We created and distributed a survey that gathered information about participants' personal characteristics, clinical specialty, training, and current practice as well as measuring their confidence assessing lupus-related rashes in various skin tones.Study Sample: Practitioners from the fields of rheumatology, dermatology, and internal medicine in the greater St. Louis area (Missouri, USA) participated in the survey.Analysis: We compared practitioners' mean confidence levels assessing lupus-related rashes in patients with fair skin and P-SOC with a linear mixed effects model and used univariate and multivariate linear regression models to determine if the aforementioned factors correlated with confidence.Results: Participants' mean confidence in diagnosing lupus-related rashes in P-SOC was significantly lower than assessing such findings in patients with fair skin (p = .009). Several factors correlated with confidence level at a univariate level; however, the multivariate model revealed experience as the only factor significantly associated with confidence (p = .001). Conclusions: Providers report significantly less confidence assessing lupus-related rashes in P-SOC than in patients with fair skin. Our analysis demonstrates that experience positively correlates with confidence and suggests that interventions which enhance practitioners' exposure to and experience with these rashes in P-SOC can improve clinical confidence as well as patient outcomes.

Update on ophthalmic manifestations of systemic lupus erythematosus: pathogenesis and precision medicine.

PURPOSE OF REVIEW: Systemic lupus erythematosus (SLE) is an autoimmune disease with manifestations in multiple organs including the eyes. Several ocular manifestations like dry eye, retinopathy, and choroidopathy have been linked with specific systemic manifestations like lupus nephritis or CNS disease. Furthermore, the presence of ocular manifesattions can correlated with the severity of SLE. Finally, some medications used in the treatment of uveitis can present with lupus-like disease. Therefore, communication between the ophthalmologist and rheumatologist is vital. RECENT FINDINGS: Ocular and systemic manifestations of SLE can be linked by common pathological processes including immune complex deposition, complement fixation, and vascular injury. Recent research correlating ophthalmic imaging with SLE disease has yielded heterogeneous results likely due to the clinical heterogeneity of SLE, but molecular technologies have and will continue to yield contributions to the emergence of new therapeutics for the treatment of SLE. SUMMARY: Ocular manifestations are prevalent in patients with SLE. The association with certain manifestations and other disease manifestations highlights the importance of collaboration between the ophthalmologist and rheumatologist. Additional research utilizing clinico-molecular techniques will likely continue to improve our knowledge in the treatment of SLE in the future.

Applying Educational Theory to Optimize Trainee Education in the Ambulatory Virtual Care Environment.

Virtual care (VC) encounters have become an essential part of outpatient clinical care. The theory of situated learning and legitimate peripheral participation posits that medical trainees learn best when they participate in authentic patient care experiences and engage effectively with their preceptors, members of the health care team, and the clinical learning environment. This theory can provide a framework from which to approach teaching in the VC setting, whereby preceptors may capitalize on the unique learning and assessment opportunities provided during VC encounters and optimize educational experiences for trainees as well as clinical outcomes for patients. In this monograph, we propose an approach grounded in situated learning and legitimate peripheral participation for teaching in the VC environment, particularly during real-time video visits.

Unnecessary complexity of home medication regimens among seniors.

OBJECTIVE: To determine whether seniors consolidate their home medications or if there is evidence of unnecessary regimen complexity. METHODS: Face-to-face interviews were conducted with 200 community-dwelling seniors >70 years in their homes. Subjects demonstrated how they took their medications in a typical day and the number of times a day patients would take medications was calculated. A pharmacist and physician blinded to patient characteristics examined medication regimens and determined the fewest number of times a day they could be taken by subjects. RESULTS: Home medication regimens could be simplified for 85 (42.5%) subjects. Of those subjects not optimally consolidating their medications, 53 (26.5%) could have had the number of times a day medications were taken reduced by one time per day; 32 (16.0%) reduced by two times or more. The three most common causes of overcomplexity were (1) misunderstanding medication instructions, (2) concern over drug absorption (i.e. before meals), and (3) perceived drug-drug interactions. CONCLUSION: Almost half of seniors had medication regimens that were unnecessarily complicated and could be simplified. This lack of consolidation potentially impedes medication adherence. PRACTICE IMPLICATIONS: Health care providers should ask patients to explicitly detail when medication consumption occurs in the home.

Hiring and screening practices of agencies supplying paid caregivers to older adults.

OBJECTIVES: To assess what screening practices agencies use in hiring caregivers and how caregiver competency is measured before assigning responsibilities in caring for older adults. DESIGN: One-to-one phone interviews in which interviewers posed as prospective clients seeking a caregiver for an older adult relative. SETTING: Cross-sectional cohort of agencies supplying paid caregivers to older adults in Illinois, California, Florida, Colorado, Arizona, Wisconsin, and Indiana. PARTICIPANTS: Four hundred sixty-two home care agencies were contacted, of which 84 were no longer in service, 165 offered only nursing care, and 33 were excluded; 180 agencies completed interviews. MEASUREMENTS: Agencies were surveyed about their hiring methods, screening measures, training practices, skill competencies assessments, and supervision. Two coders qualitatively analyzed open-ended responses. RESULTS: To recruit caregivers, agencies primarily used print and Internet (e.g., Craigslist.com) advertising (n = 69, 39.2%) and word-of-mouth referrals (n = 49, 27.8%). In hiring, agencies required prior "life experiences" (n = 121, 68.8%) few of which (n = 33, 27.2%) were specific to caregiving. Screening measures included federal criminal background checks (n = 96, 55.8%) and drug testing (n = 56, 31.8%). Agencies stated that the paid caregiver could perform skills, such as medication reminding (n = 169, 96.0%). Skill competency was assessed according to caregiver self-report (n = 103, 58.5%), testing (n = 62, 35.2%), and client feedback (n = 62, 35.2%). General caregiver training length ranged from 0 to 7 days. Supervision ranged from none to weekly and included home visits, telephone calls, and caregivers visiting the central office. CONCLUSION: Using an agency to hire paid caregivers may give older adults and their families a false sense of security regarding the background and skill set of the caregiver.