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Development and ImplementaEon of a Pediatric Rheumatology Curriculum for the Pediatric Resident Pediatric Allergy, Immunology and Rheumatology, Baylor College of Medicine and Texas Children’s Hospital Miriah Gillispie and Amanda Brown • During this clinical experience, residents were shown the pediatric gait, arms, legs, and spine (pGALS) exam by a fellow or aeending • AUer allowing for pracEce, they were observed performing the exam and given real Eme feedback and evaluaEon • They were also encouraged to download the pGALS app as a reference Methods OutpaEent Experience Conclusion/Future DirecEon References Background/IntroducEon Results Results • We were able to effecEvely increase comfort level with regards to history taking, physical exam skills, laboratory evaluaEon, and rheumatology referrals for those paEents who present with concerns for an autoimmune process • We plan to conEnue using this curriculum for those residents rotaEng through rheumatology • We also plan to expand the topics to include addiEonal lectures on rheumaEc fever, chronic nonbacterial osteomyeliEs, etc • We may also introduce workshops for interested community PCPs in order to expand their fund of knowledge regarding pediatric rheumatology topics • Pediatric autoimmune diseases are among the most common chronic medical condiEons afflicEng children, even more common than both cysEc fibrosis and sickle cell anemia 1,2 • EsEmates are that 1 in 250 children have a form of juvenile arthriEs or other autoimmune condiEon, which is almost 300,000 pediatric paEents naEonwide 3 Fig 1. DistribuEon of pediatric rheumatologists naEonwide • Despite the prevalence, there are only 407 pracEcing pediatric rheumatologists across the country as of 2015 4 • EsEmates suggest 10% of these rheumatologists will reEre in the next several years and demand already exceeds supply by 25-50% 4 • Currently paEents who do have access to care oUen travel >4 hours to receive care and new paEents oUen have to wait weeks to months for an appointment 4 • Exposure to pediatric rheumatology teaching for residents is limited and several medical schools and residency programs do not have access to this type of curriculum causing PCPs to be ill equipped to diagnose and provide preliminary treatment 4 • In insEtuEons with pediatric rheumatology, average exposure and teaching Eme is esEmated at 5 hours for the enErety of residency • A standard curriculum covering “bread and bueer” pediatric rheumatology in a case based format will help increase resident comfort level with history taking, physical examinaEon, work up, and referrals for paEents who present with signs and symptoms concerning for autoimmune diseases • To develop a curriculum to increase comfort level of pediatrics residents with regards to history taking, physical exam skills, laboratory evaluaEon, and referral paeerns perEnent to paEents who present with concerns for autoimmune disease • All pediatrics and med-peds residents at our insEtuEon were anonymously surveyed to get their opinion on which topics in rheumatology they thought were most important and also on their preference for content delivery • Based on responses, a series of six lectures were composed in a case based, interacEve format • The project includes 30-minute case based lectures received by second year pediatrics and third year med-peds residents rotaEng through the inpaEent rheumatology service as well as real Eme feedback on physical exam skills in clinic • Pre and post surveys were used to evaluate improvement in comfort level with rheumatology topics Hypothesis 1. The Cys0c Fibrosis Founda0on. Retrieved on August 3, 2017 from hNps://www.cff.org/About-Us/ 2. Center for Disease Control and Preven0on. (August 4, 2017). Sickle Cell Disease Data and Sta0s0cs. Retrieved from hNps ://www.cdc.gov/ncbddd/sicklecell/data.html 3. Arthri0s by Numbers. (2015, December 11). Retrieved on July 15, 2017 from hNps://www.arthri0s.org/Documents/Sec0ons/About-Arthri0s/arthri0s-facts-stats-figures.pdf 4. Health Resources and Services Administra0on (HRSA). Report to Congress ‘The Pediatric Rheumatology Workforce: A Study of the Supply and Demand for Pediatric Rheumatologists” (February 2007) 5. Smith N, Jandial S, Rae L, Foster H. pGALs. Educa0on. Apple App Store Vers 1.6. Boxmodel Digital Media Limited, 2016. Web. Sept 2017. Cases ObjecEve Fig 7. Word cloud presenEng most commonly used words in free text response on survey asking Strongly Agree Agree Neutral Disagree Strongly Disagree 0 Case 6 6 year old with a rash Case 2 5 year old with “T-Rex” arms Case 3 16 year old with joint pain Case 1 3 year old with fevers Case 4 12 year old with weakness Case 5 5 year old with red eyes a. b. c. f. e. d. Fig 2. a) IniEal slide for periodic fever, adeniEs, pharyngiEs, aphthous stomaEEs (PFAPA) case; b) IniEal slide for the juvenile idiopathic arthriEs (JIA) case with pediatrics gait, arms, legs, and spine (pGALS) exam; c) IniEal slide for the systemic lupus erythematosus (SLE) case; d) IniEal slide for the juvenile dermatomyosiEs (JDMS) case; e) IniEal slide for the Kawasaki Disease (KD) case; f) IniEal slide for the Henoch-Schönlein purpura (HSP) case Fig 3. pGALS app available free for iPhone 5 Pre RotaEon Assessment of Resident Comfort with Work Up Post RotaEon Assessment of Resident Comfort with Work up Pre RotaEon Assessment of Resident Comfort with Musculoskeletal Exam Post RotaEon Assessment of Resident Comfort with Musculoskeletal Exam Pre RotaEon Assessment of Resident Comfort with Laboratory InterpretaEon Post RotaEon Assessment of Resident Comfort with Laboratory InterpretaEon Pre RotaEon Assessment of Resident Comfort with Rheumatology Referral Post RotaEon Assessment of Resident Comfort with Rheumatology Referral Lectures Delivered to Residents By Month Feb March April May June July Aug Fig 5b. AJtudes of residents with regard to comfort level with musculoskeletal exams aUer inpaEent rheumatology rotaEon and clinic experience 0 2 4 6 Residents Feb March April May June July Aug 0 2 4 6 Fig 6b. AJtudes of residents with regard to comfort with laboratory interpretaEon in a paEent who presents with concern for autoimmune disease aUer the inpaEent rheumatology rotaEon Residents Fig 8a. AJtudes of residents regarding comfort with rheumatology referral prior to inpaEent and clinic experience with rheumatology Feb March April May June July Aug 0 2 4 6 Residents PFAPA SLE HSP JIA with pGALS JDMS KD Fig 9. Lectures broken down by frequency Feb March April May June July Aug 2 6 10 14 18 Residents Feb March April May June July Aug Fig 4b. AJtudes of residents with regard to comfort level with autoimmune disease work up aUer inpaEent rheumatology rotaEon 0 2 4 6 Residents Feb March April May June July Aug 0 2 4 6 Fig 8b. AJtudes of residents regarding comfort with rheumatology referral aUer inpaEent and clinic experience with rheumatology Residents Fig 5a. AJtudes of residents with regard to comfort with musculoskeletal exams prior to inpaEent rheumatology rotaEon and clinic experience Feb March April May June July Aug 0 2 4 6 Residents Feb March April May June July Aug Fig 4a. AJtudes of residents with regard to comfort level with autoimmune disease work up prior to inpaEent rheumatology rotaEon 0 2 4 6 2 4 6 Feb March April May June July Aug Fig 6a. AJtudes of residents with regard to comfort with laboratory interpretaEon in a paEent who presents with concerns for autoimmune disease prior to the inpaEent rheumatology rotaEon Residents Residents

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Page 1: Development and Implementaon of a Pediatric … · hNps://¬gures.pdf 4. Health Resources and Services Administra0on ... JIA with pGALS

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Abstract

DevelopmentandImplementaEonofaPediatricRheumatologyCurriculumforthePediatricResident

PediatricAllergy,ImmunologyandRheumatology,BaylorCollegeofMedicineandTexasChildren’sHospital

MiriahGillispieandAmandaBrown

•  Duringthisclinicalexperience,residentswereshownthepediatricgait,arms,legs,andspine(pGALS)exambyafelloworaeending

•  AUerallowingforpracEce,theywereobservedperformingtheexamandgivenrealEmefeedbackandevaluaEon

•  TheywerealsoencouragedtodownloadthepGALSappasareference

Methods

OutpaEentExperience

Conclusion/FutureDirecEon

References

Background/IntroducEon Results Results

•  WewereabletoeffecEvelyincreasecomfortlevelwithregardstohistorytaking,physicalexamskills,laboratoryevaluaEon,andrheumatologyreferralsforthosepaEentswhopresentwithconcernsforanautoimmuneprocess

•  WeplantoconEnueusingthiscurriculumforthoseresidentsrotaEngthroughrheumatology

•  WealsoplantoexpandthetopicstoincludeaddiEonallecturesonrheumaEcfever,chronicnonbacterialosteomyeliEs,etc

•  WemayalsointroduceworkshopsforinterestedcommunityPCPsinordertoexpandtheirfundofknowledgeregardingpediatricrheumatologytopics

•  PediatricautoimmunediseasesareamongthemostcommonchronicmedicalcondiEonsafflicEngchildren,evenmorecommonthanbothcysEcfibrosisandsicklecellanemia1,2

•  EsEmatesarethat1in250childrenhaveaformofjuvenilearthriEsorotherautoimmunecondiEon,whichisalmost300,000pediatricpaEentsnaEonwide3Fig1.DistribuEonofpediatricrheumatologistsnaEonwide

•  Despitetheprevalence,thereareonly407pracEcingpediatricrheumatologistsacrossthecountryasof20154

•  EsEmatessuggest10%oftheserheumatologistswillreEreinthenextseveralyearsanddemandalreadyexceedssupplyby25-50%4

•  CurrentlypaEentswhodohaveaccesstocareoUentravel>4hourstoreceivecareandnewpaEentsoUenhavetowaitweekstomonthsforanappointment4

•  ExposuretopediatricrheumatologyteachingforresidentsislimitedandseveralmedicalschoolsandresidencyprogramsdonothaveaccesstothistypeofcurriculumcausingPCPstobeillequippedtodiagnoseandprovidepreliminarytreatment4

•  IninsEtuEonswithpediatricrheumatology,averageexposureandteachingEmeisesEmatedat5hoursfortheenEretyofresidency

•  Astandardcurriculumcovering“breadandbueer”pediatricrheumatologyinacasebasedformatwillhelpincreaseresidentcomfortlevelwithhistorytaking,physicalexaminaEon,workup,andreferralsforpaEentswhopresentwithsignsandsymptomsconcerningforautoimmunediseases

•  Todevelopacurriculumtoincreasecomfortlevelofpediatricsresidentswithregardstohistorytaking,physicalexamskills,laboratoryevaluaEon,andreferralpaeernsperEnenttopaEentswhopresentwithconcernsforautoimmunedisease

•  Allpediatricsandmed-pedsresidentsatourinsEtuEonwereanonymously

surveyedtogettheiropiniononwhichtopicsinrheumatologytheythoughtweremostimportantandalsoontheirpreferenceforcontentdelivery

•  Basedonresponses,aseriesofsixlectureswerecomposedinacasebased,interacEveformat

•  Theprojectincludes30-minutecasebasedlecturesreceivedbysecondyearpediatricsandthirdyearmed-pedsresidentsrotaEngthroughtheinpaEentrheumatologyserviceaswellasrealEmefeedbackonphysicalexamskillsinclinic

•  Preandpostsurveyswereusedtoevaluateimprovementincomfortlevelwithrheumatologytopics

Hypothesis

1.   TheCys0cFibrosisFounda0on.RetrievedonAugust3,2017fromhNps://www.cff.org/About-Us/2.   CenterforDiseaseControlandPreven0on.(August4,2017).SickleCellDiseaseDataandSta0s0cs.Retrievedfrom

hNps://www.cdc.gov/ncbddd/sicklecell/data.html3.   Arthri0sbyNumbers.(2015,December11).RetrievedonJuly15,2017from

hNps://www.arthri0s.org/Documents/Sec0ons/About-Arthri0s/arthri0s-facts-stats-figures.pdf4.   HealthResourcesandServicesAdministra0on(HRSA).ReporttoCongress‘ThePediatricRheumatologyWorkforce:AStudyoftheSupplyand

DemandforPediatricRheumatologists”(February2007)5.   SmithN,JandialS,RaeL,FosterH.pGALs.Educa0on.AppleAppStoreVers1.6.BoxmodelDigitalMediaLimited,2016.Web.Sept2017.

Cases

ObjecEveFig7.WordcloudpresenEngmostcommonlyusedwordsinfreetextresponseonsurveyasking

StronglyAgree

Agree

Neutral

Disagree

StronglyDisagree

0

Case66yearoldwitharash

Case25yearoldwith“T-Rex”arms

Case316yearoldwithjointpain

Case13yearoldwithfevers

Case412yearoldwithweakness

Case55yearoldwithredeyes

a. b. c.

f.e.d.

Fig2.a)IniEalslideforperiodicfever,adeniEs,pharyngiEs,aphthousstomaEEs(PFAPA)case;b)IniEalslideforthejuvenileidiopathicarthriEs(JIA)casewithpediatricsgait,arms,legs,andspine(pGALS)exam;c)IniEalslideforthesystemiclupuserythematosus(SLE)case;d)IniEalslideforthejuveniledermatomyosiEs(JDMS)case;e)IniEalslidefortheKawasakiDisease(KD)case;f)IniEalslidefortheHenoch-Schönleinpurpura(HSP)case

Fig3.pGALSappavailablefreeforiPhone5

PreRotaEonAssessmentofResidentComfortwithWorkUp

PostRotaEonAssessmentofResidentComfortwithWorkup

PreRotaEonAssessmentofResidentComfortwithMusculoskeletalExam

PostRotaEonAssessmentofResidentComfortwithMusculoskeletalExam

PreRotaEonAssessmentofResidentComfortwithLaboratoryInterpretaEon

PostRotaEonAssessmentofResidentComfortwithLaboratoryInterpretaEon

PreRotaEonAssessmentofResidentComfortwithRheumatologyReferral

PostRotaEonAssessmentofResidentComfortwithRheumatologyReferral

LecturesDeliveredtoResidentsByMonth

Feb March April May June July Aug

Fig5b.AJtudesofresidentswithregardtocomfortlevelwithmusculoskeletalexamsaUerinpaEentrheumatologyrotaEonandclinicexperience

0

2

4

6

Re

siden

ts

FebMarchAprilMayJuneJulyAug0

2

4

6

Fig6b.AJtudesofresidentswithregardtocomfortwithlaboratoryinterpretaEoninapaEentwhopresentswithconcernforautoimmunediseaseaUertheinpaEentrheumatologyrotaEon

Re

siden

ts

Fig8a.AJtudesofresidentsregardingcomfortwithrheumatologyreferralpriortoinpaEentandclinicexperiencewithrheumatology

FebMarchAprilMayJuneJulyAug0

2

4

6

Resid

ents

PFAPA

SLE

HSP

JIAwithpGALS

JDMS

KD

Fig9.Lecturesbrokendownbyfrequency

Feb March April May June July Aug

2

6

10

14

18

Resid

ents

FebMarchAprilMayJuneJulyAug

Fig4b.AJtudesofresidentswithregardtocomfortlevelwithautoimmunediseaseworkupaUerinpaEentrheumatologyrotaEon

0

2

4

6

Re

siden

ts

FebMarchAprilMayJuneJulyAug0

2

4

6

Fig8b.AJtudesofresidentsregardingcomfortwithrheumatologyreferralaUerinpaEentandclinicexperiencewithrheumatology

Resid

ents

Fig5a.AJtudesofresidentswithregardtocomfortwithmusculoskeletalexamspriortoinpaEentrheumatologyrotaEonandclinicexperience

FebMarchAprilMayJuneJulyAug0

2

4

6

Resid

ents

FebMarchAprilMayJuneJulyAug

Fig4a.AJtudesofresidentswithregardtocomfortlevelwithautoimmunediseaseworkuppriortoinpaEentrheumatologyrotaEon

0

2

4

6

2

4

6

FebMarchAprilMayJuneJulyAug

Fig6a.AJtudesofresidentswithregardtocomfortwithlaboratoryinterpretaEoninapaEentwhopresentswithconcernsforautoimmunediseasepriortotheinpaEentrheumatologyrotaEon

Resid

ents

Residen

ts

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