COMMENTARY

 

A VIEW FROM THE PEDIATRIC RHEUMATOLOGY PEANUT GALLERY

 

WANTED: MORE PEDIATRIC RESIDENTS IN RHEUMATOLOGY CLINIC

 

I have recently noted that several rheumatology electives are not attracting as many pediatric residents as they have in the past. Part of the explanation may lie with the view of the universe of the pediatric residency director. I know the details of one program where previously the pediatric program allowed first year residents only to choose between pulmonary, neurology, and rheumatology for a two week or month block as a first year resident. A change in residency directors led to the residents freely choosing their electives. As that residency director’s emphasis and love is ICU, there appeared to be a built-in bias towards ICU experiences and inpatient care that appears to come from more what the director does and cares about than what the director says (modeling that says “inpatient care is where it’s at!!!”)

 So, though that program director would likely not agree, it appears to me that that particular residency program emphasized and continues to emphasize more inpatient than outpatient experience.  What outpatient subspecialty experience there is favors subspecialists who are very conspicuous in the inpatient setting. To be fair, this inpatient and intensive care emphasis may have as much to do with the financial and workforce needs of medical institutions as with educational priorities (If the residents don’t do the work in intensive care, who would replace them?).  Inpatient units that bring in the most money and publicity may have more power to pull residents into their service. From this view of the universe, it may be hard to accept the possibility that a primary care physician and non-NICU/PICU subspecialists need less ICU/NICU (4 months maximum may be sufficient) and more non-hospital care focused outpatient experience.  The residency experience may meet the necessary residency review committee guidelines but do an inadequate, or even a poor job of preparing a resident for life as an outpatient physician, generalist or subspecialty.

 I would suggest that the pediatric resident’s outpatient experience should be as much in specialties not often visible on the inpatient services (e.g., dermatology, orthopedics, rheumatology, genetics, sports medicine, development, adolescent medicine, outpatient infectious disease, chronic disease, physiatry) as in the services the residents commonly consult for inpatients (pulmonary, cardiology, hematology-oncology, infectious disease, gastroenterology, endocrine). It is important to note that one general pediatric practice in Chicago that I know with 2000 patients usually had no NICU or PICU patients in the last year and only 12 brief hospitalizations of inpatients while maintaining a busy outpatient practice.

 I’m aware that other pediatric programs may share this problem, but others may have plenty of residents who rotate through their outpatient elective. If your chairperson is a rheumatologist or your program director a rheumatologist, you may have residents in your clinics all the time. Yet I suspect that in many of the US pediatric programs who are reacting to changes forced upon them by the 80 hour workweek rule, the outpatient clinic exposure for residents may have declined and may be inadequate. A post-call resident must be out of the hospital by 1 PM on the post-call day and may miss afternoon clinics. Continuity clinics may be switched to other days of the week and squeeze out subspecialty clinics. For those of us in rheumatology, the result may be less time for the resident to learn the musculoskeletal exam, less time to see a child with arthritis, less time to see the well lupus patient (not the severely ill lupus patient only), and less time to appreciate the child thriving on biologics.

For rheumatology, it’s our challenge to convince residents, chairpersons, program directors, and others that ours is not just a small subspecialty of rare diseases. We must repeat our mantras. Six million children in the world suffer from rheumatic diseases and 250,000 children in the US have chronic arthritis. JIA is more common than more well known childhood diseases such as juvenile diabetes, acute leukemia, and muscular dystrophy.

But we in rheumatology do have a larger image problem, a profile challenge. We swim upstream against the large numbers of adults with chronic arthritis, mostly osteoarthritis. No one knows that kid get arthritis despite efforts by some arthritis organizations. For many laypersons, saying a child has arthritis is a contradiction, an absurdity, an oxymoron. Our kids have low grade, low profile chronic illnesses that cause suffering and lower quality of life, but are not usually life-threatening. So our kid’s problems just don’t get attention compared to adult arthritis and other childhood problems. This is a major obstacle. We often have adult rheumatology organizations do our development and education efforts and these relationships may hamper our efforts as well. As previously suggested in this commentary space, it is likely that our needs will never be given adequate emphasis in an adult arthritis organization.

So we must work on showing our medical community and the general public that we are an important subspecialty-not more important, but as important. As I have discussed before, the key may be in demonstrating our vital role as non-operative musculoskeletal disease specialists. I believe that no one knows the differential of musculoskeletal problems in children better than an experienced pediatric rheumatologist-not an orthopedist, not a sports medicine pediatrician, no one. We have to be assertive in advocating this educational role. We need to show how important musculoskeletal problems are in resident education.

 

What strategies should we use?

A) Educate our peers    

Our first and toughest obstacle is convincing the Department Chairperson, the Residency Director, and the Chief Residents that this musculoskeletal experience is important and is particularly crucial for pediatric residents going into primary care and emergency medicine. This may be a tough sell if the Director is an inpatient physician, e.g., ICU, NICU, or cardiology. These inpatient and procedure-focused physicians, though they may be wonderful inpatient physicians, often have no idea what a rheumatologist and other musculoskeletal physicians do in the real world.  They may believe that if PICU has 48 months of resident time, cardiology 45 months, and rheumatology 8 months in a 3 year residency span, then that is how things should be. We do have some data to use:

1)10% to 30% of outpatient pediatric visits may involve a musculoskeletal

    complaint. 1-3

2) One survey of pediatricians 10 years out of training identified

    musculoskeletal training as the weakest area of their pediatric training.4 

3) In another study, over 50% of one group of residents and attending

    physicians were found to be deficient in musculoskeletal knowledge

    base and the ability to do an adequate musculoskeletal exam in adults

    and children.5

4) In one more study, 64 % of referrals to a pediatric orthopedic practice

    by pediatricians were inappropriate. The authors concluded that the

    referrals indicated either a lack of textbook knowledge or a lack of

    examination skills and the appropriate diagnostic tools. 6

Gaining a sympathetic ear in pediatric administration is helpful but not required. We should be ready with other ideas if the Director and Chiefs are not convinced that most of the pediatric residents should be exposed to outpatient musculoskeletal disorders in children by an outpatient experience. We should work on the chief residents and residents with other educational offerings to fill in the gaps and hope that others will eventually find their way to our clinics.

B) Try new strategies to educate and recruit the pediatric residents           

These strategies might include:

1)       Broaden the rheumatology outpatient elective for residents and residents to include musculoskeletal clinics other than rheumatology: orthopedics, podiatry, sports medicine, neurology clinic for myopathies, and similar areas.

2)       Begin bedside rounds once a week with a resident team to demonstrate the physical findings and discuss the treatment options in a child with JIA, lupus, or JDM.

3)       Attempt to get more time on rheumatologic and musculoskeletal topics in morning reports, grand rounds, and core curriculum lectures.

4)       Partner with similar thinking musculoskeletal physicians including orthopedists, physiatrists, and sports medicine physicians-share grand rounds, morning reports, core curriculum lectures, and other opportunities.

5)       Monitor resident performance on musculoskeletal questions in in-service exams and credentialing exams-find areas to improve and point out deficiencies.

6)       Inform medical students and residents about web-based resources such as the ACR and AAP websites, PROJ, the Indiana University Pediatric Rheumatology Resource website, individual hospital websites, and other such websites.

7)       Speak with passion to the residents of the joy of caring for children with chronic musculoskeletal and rheumatic illnesses and show them your enthusiasm and skills in your time with them on the wards and in the clinics. Don’t complain.

8)       Make it known that rheumatology and other areas of autoimmune disease in 2005 are exploding with new scientific advances and new treatment and that there are many job opportunities and needs for our skills in many countries.

C) Educate the public

            This is a daunting challenge. It will take several decades. First we educate our peers better and then it will be easier to educate the layperson. In the meantime, we should use our adult rheumatology organizations for education and publicity as best we can while developing our own pediatric rheumatology organizations and foundations for the long run. No one will do it for us; we must do it on our own. Books and pamphlets help. Several books have come out that speak to the layperson as peers and are a tremendous help, including the recently published book “It’s Not Just Growing Pains”. The most important step may be developing a fund-raising foundation just for pediatric arthritis diseases, similar to the Juvenile Diabetes Research Foundation. CARRA and PRINTO may eventually develop into that fund-raising role.

 

SUMMARY

The major justification for this effort is the need for education in musculoskeletal disease of our pediatric workforce in the US and in every country. Pediatricians and pediatric residents often don’t know much about musculoskeletal diseases in children, including how to do a good musculoskeletal exam. Since many practicing pediatricians were not trained in this area, it seems likely that they may miss diagnoses and often never recognize that they have a deficiency in this area of pediatrics and seek continuing education. They may refer patients to orthopedists who themselves may not be comfortable diagnosing arthritis in kids.  The place to start is in medical schools and pediatric residencies.

Lastly, another critical justification is that this effort is vital to increasing the number of fellows in pediatric rheumatology and ultimately having sufficient pediatric rheumatologists in every country in the world.  I applaud the efforts of the ACR and PRES to bring medical students, residents, and fellows to the yearly scientific meetings.  But the day-to-day exposure of these young doctors and doctors-to-be to our amazing rheumatology outpatient world is so important for both medical education and the recruitment of fellows.  We still have much to do.

 

Charles H. Spencer, MD

Chicago

 

 

REFERENCES

      1. Craton N, Matheson GO. Training and clinical competency in

          musculoskeletal medicine. Identifying the problem. Sports Med. 1993:15:

          328-337

2. de Inocencio J. Musculoskeletal pain in primary pediatric care: An analysis

     of 1000 consecutive general pediatric clinic visits. Pediatrics.

    1998;102(6):E63

3.  Schwend RM, Geiger J. Outpatient pediatric orthopedics: common and

     important conditions. Pediatr Clin North Am. 1998;45:943-971

4.  Taras HL. Ten years of graduates evaluate a pediatric residency program.

     Am J Dis Child. 1990;144:1102-1105
5.  Matzkin E, Smith EL, Freccero D, et al. Adequacy of education

     in musculoskeletal medicine. J Bone Joint Surg. AM 2005 Feb;87-

     A(2):310-314

      6.  Reeder BM, Lyne ED, Patel DR, et al. Referral patterns to a pediatric

     orthopedic clinic: Implications for education and practice. Pediatrics. 

     2004;113:e163-e167