What makes a rheumatologist? And how do we measure a fellow’s progress toward competency and readiness for practice within their subspecialty? In recent years, the evolution of graduate medical education, which includes the American Council for Graduate Medical Education (ACGEM) core competencies, the Next Accreditation System (NAS) and the use of entrustable professional activities (EPAs), has had stakeholders across subspecialties—including rheumatology—probing these questions in order to improve fellowship training and assessment.
In 2013, through a collaborative process, key stakeholders from internal medicine subspecialties, including rheumatology, worked with the Association of Specialty Professors, the Alliance for Academic Internal Medicine, the American Board of Internal Medicine and the ACGEM to develop a uniform set of reporting milestones to assess trainees. Additionally, each subspecialty was tasked with developing EPAs, which identify the aptitudes and expertise of an unsupervised practitioner. For rheumatology, this responsibility fell to members of the NAS working group of the American College of Rheumatology (ACR) Committee on Rheumatology Training and Workforce Issues.
In their latest paper published in the August 2016 issue of Arthritis Care & Research, Calvin R. Brown Jr., MD, of the Division of Rheumatology, Northwestern University, Feinberg School of Medicine in Chicago, and colleagues describe in detail the collaboration process and the assessment tools developed.
The Results
After multiple development summits and working group meetings, 23 internal medicine subspecialty reporting milestones and 14 EPAs for rheumatology were developed and refined. These tools “stipulate reasonable and measurable expectations for rheumatologists-in-training,” write the authors. “Together, these tools aim to promote enrichment and greater accountability in the training of fellows. Additionally, the EPAs define, for all stakeholders, the expertise of a rheumatologist in practice. … Progression from competency-based graduate medical education to competency-based medical practice is the worthy goal of these new tools.”
In December 2013, the ACR Executive Committee endorsed the internal medicine subspecialty reporting milestones, which were implemented in July 2014. The milestones are rooted in and organized by the ACGEM’s six core competencies: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism and systems-based practice. “The first [assessment] submission cycle for the subspecialty reporting milestones to the ACGME by rheumatology training programs, along with all other internal medicine subspecialty training programs, was completed Jan. 9, 2015,” write the authors.
According to the authors, the milestones may serve many functions. They are designed to benefit rheumatology fellowship programs by providing a framework by which programs can make curricular decisions, provide fellows with feedback and meet stakeholder expectations via professional self-regulation. Additionally, the ACGME is using them in its NAS continuous accreditation process.
The reporting milestones include:
- Managing patients with progressive responsibility and independence (patient care);
- Knowledge of diagnostic testing and procedures (medical knowledge);
- Learning and improving via feedback (practice-based learning and improvement);
- Communicating effectively in interprofessional teams (interpersonal and communication skills);
- Responding to each patient’s unique characteristics and needs (professionalism); and
- Recognizing system error and advocating for system improvement (systems-based practice).
In October 2013, the ACR NAS working group was created to develop rheumatology EPAs, which aim to link competencies to clinical practice and transition trainees to a workplace-based assessment. They are a set of tasks or responsibilities any practicing rheumatologist should be able to perform and can be evaluated by supervisors. In August 2014, the ACR board of Directors approved the final 14 EPAs for rheumatology and implemented them.
EPAs include:
- Managing the care of patients with acute and chronic, common and complex rheumatologic diseases across multiple care settings;
- Prescribing and managing immunomodulatory therapy;
- Demonstrating professional, compassionate and ethical behavior;
- Facilitating the learning of patients, families and members of the interprofessional teams; and
- Engaging in life-long learning.
The EPAs “illustrate the difference between rheumatologists and other clinicians who may provide care for individuals with musculoskeletal and rheumatic diseases,” write the authors. “With the development of EPAs, there is now a standardized language ensuring a common understanding of expectations to be achieved during training.”
Read the full article, milestones and rheumatology EPAs.
Brown Jr. CR, Criscione-Schreiber L, O’Rourke KS, et al. What is a rheumatologist and how do you make one? Arthritis Care Res (Hoboken). 2016 Aug:68(8):1166–1172. doi: 10.1002/acr.22817. [Epub ahead of print]
