Heather McDonald-Blumer

The global challenges and opportunities in the practice of rheumatology: White paper by the World Forum on Rheumatic and Musculoskeletal Diseases

Rheumatic and musculoskeletal diseases (RMDs) represent a multitude of degenerative, inflammatory and auto-immune conditions affecting millions of people worldwide. Persons with these diseases may potentially experience severe chronic pain, joint damage, increasing disability and even death. With an increasingly ageing population, the prevalence and burden of RMDs are predicted to increase, placing greater demands on the global practice of rheumatology and related healthcare budgets. Effective treatment of RMDs currently faces a number of challenges in both the developed and developing world, and individual countries may face more specific local challenges. However, limited understanding of the burden of RMDs amongst public health professionals and policy-makers means that these diseases are often not considered a public health priority. The objective of this review is to increase awareness of the RMDs and to identify opportunities to address RMD challenges on both a local and global scale. On 26 September 2014, rheumatology experts from five different continents met at the World Forum on Rheumatic and Musculoskeletal Diseases (WFRMD) to discuss and identify some key challenges for the RMDs community today. The outcomes are presented in this review, focusing on access to rheumatology services, diagnostics and therapies, rheumatology education and training and on clinical trials, as well as investigator-initiated and epidemiological research. The long-term vision of the WFRMD is to increase perception of the RMDs as a major burden to society and to explore potential opportunities to improve global and local RMD care.

Impact of a formal mentoring program on academic promotion of Department of Medicine faculty: A comparative study

Abstract Purpose: To evaluate the impact of a formal mentoring program on time to academic promotion and differences in gender-based outcomes. Methods: Comparisons of time to promotion (i) before and after implementation of a formal mentoring program and (ii) between mentored and non-mentored faculty matched for covariates. Using paired-samples t-testing and mixed repeated measures ANCOVA, we explored the effect of mentor assignment and influence of gender on time to promotion. Results: Promotional data from 1988 to 2010 for 382 faculty members appointed before 2003 were compared with 229 faculty members appointed in 2003 or later. Faculty appointed in 2003 or later were promoted 1.2 years (mean) sooner versus those appointed before 2003 (3.7 [SD = 1.7] vs. 2.5 [SD = 2], p < 0.0001). Regardless of year of appointment, mentor assignment appears to be significantly associated with a reduction in time to promotion versus non-mentored (3.4 [SD = 2.4] vs. 4.4 [SD = 2.6], p = 0.011). Gender effects were statistically insignificant. Post hoc analyses of time to promotion suggested that observed differences are not attributable to temporal effects, but rather assignment to a mentor. Conclusions: Mentoring was a powerful predictor of promotion, regardless of the year of appointment and likely benefited both genders equally. University resource allocation in support of mentoring appears to accelerate faculty advancement.

Utility and feasibility of musculoskeletal ultrasonography (MSK US) in rheumatology practice in Canada: needs assessment

The utility of musculoskeletal ultrasound (MSK US) is being extensively explored and evaluated amongst European rheumatologists. However, utilization of MSK US by rheumatologists in Canada is much less common. This study aimed to evaluate the current use of MSK US in Canadian rheumatology practice, to determine beliefs and attitudes towards MSK US, and to determine factors that may encourage or limit its use. A 13-question needs assessment questionnaire was developed. All Canadian rheumatologists were invited via e-mail to participate in the survey. The overall response rate was 156/470 (33%). Fifty-one percent of participants used MSK US in their clinical practice. Lack of training appeared to be the main obstacle to its current use. Eighty-three percent believed that MSK US should be performed by rheumatologists and expressed a willingness to learn the technique. Skills offering greatest clinical utility were the assessment of inflammatory arthritis in small joints (i.e., hands (metacarpophalyngeal and proximal interphalangeal joints), wrists, feet (metatarsophalyngeal), shoulders, and ankles. Limited available time, equipment costs, and difficulties with billing were the main obstacles to MSK US utilization in the clinical setting. There is a great level of interest in learning and applying MSK US in Canadian rheumatology practice. The balance between added clinical value and lack of remuneration, equipment associated costs, and time to complete training is the major limiting factor influencing rheumatologists’ willingness to take on MSK US. Training programs must be relevant to rheumatologists’ needs before MSK US will be adopted into routine clinical practice in Canada.

Alterations of bone mineral density, bone microarchitecture and strength in patients with ankylosing spondylitis: a cross-sectional study using high-resolution peripheral quantitative computerized tomography and finite element analysis

IntroductionAnkylosing spondylitis (AS) is an inflammatory disease associated with new bone formation and an increased risk of osteoporosis and fractures. The negative effects of AS on bone microarchitecture and strength are unclear. Thus, we conducted an observational study to analyze the effect of AS on bone microarchitecture and strength.MethodsPatients with AS (n = 53) and non-AS subjects (n = 85) were recruited for the study. All subjects underwent clinical evaluation, DXA and high-resolution peripheral quantitative CT scans (HRpQCT).ResultsThe AS patients were aged 44 ± 12 (mean ± standard deviation) years and had a median disease duration of 17 (interquartile range: 7–27) years. They were found to have lower cortical, trabecular and total vBMD at the distal radius and tibia than non-AS subjects on multivariable regression analysis. Cortical parameters such as cortical thickness and porosity, and bone strength parameters such bone stiffness and stress as estimated by finite element analysis (FEA) in AS patients were significantly worse than that of-non-AS subjects. Among patients with AS, male sex, mSASSS greater than zero and HLA-B27 negative status were associated with worse bone microarchitecture.ConclusionsPatients with AS have worse bone mineral density, microarchitecture and strength when compared to non-AS subjects. More research is needed to understand the mechanisms underlying bone pathology in AS and to assess the effect of treatments such as TNF inhibitors on bone quality and fracture risk.

Standardized patient simulation versus didactic teaching alone for improving residents’ communication skills when discussing goals of care and resuscitation: A randomized controlled trial

Background: Communication skills are important when discussing goals of care and resuscitation. Few studies have evaluated the effectiveness of standardized patients for teaching medical trainees to communicate about goals of care. Objective: To determine whether standardized patient simulation offers benefit over didactic sessions alone for improving skill and comfort discussing goals of care. Design and intervention: Single-blind, randomized, controlled trial of didactic teaching plus standardized patient simulation versus didactic teaching alone. Participants: First-year internal medicine residents. Main measures: Changes in communication comfort and skill between baseline and 2 months post-training assessed using the Consultation and Relational Empathy measure. Key results: We enrolled 94 residents over a 2-year period. Both groups reported a significant improvement in comfort when discussing goals of care with patients. There was no difference in Consultation and Relational Empathy scores following the workshop (p = 0.79). The intervention group showed a significant increase in Consultation and Relational Empathy scores post-workshop compared with pre-workshop (35.0 vs 31.7, respectively; p = 0.048), whereas there was no improvement in Consultation and Relational Empathy scores in the control group (35.6 vs 36.0; p = 0.4). However, when the results were adjusted for baseline differences in Consultation and Relational Empathy scores in a multivariable regression analysis, group assignment was not associated with an improvement in Consultation and Relational Empathy score. Improvement in comfort scores and perception of benefit were not associated with improvements in Consultation and Relational Empathy scores. Conclusion: Simulation training may improve communication skill and comfort more than didactic training alone, but there were important confounders in this study and further studies are needed to determine whether simulation is better than didactic training for this purpose.

Feedback Credibility in a Formative Postgraduate Objective Structured Clinical Examination: Effects of Examiner Type

Background Resident perspectives on feedback are key determinants of its acceptance and effectiveness, and provider credibility is a critical element in perspective formation. It is unclear what factors influence a residents judgment of feedback credibility. Objective We examined how residents perceive the credibility of feedback providers during a formative objective structured clinical examination (OSCE) in 2 ways: (1) ratings of faculty examiners compared with standardized patient (SP) examiners, and (2) ratings of faculty examiners based on alignment of expertise and station content. Methods During a formative OSCE, internal medicine residents were randomized to receive immediate feedback from either faculty examiners or SP examiners on communication stations, and at least 1 specialty congruent and either 1 specialty incongruent or general internist faculty examiner for clinical stations. Residents rated perceived credibility of feedback providers on a 7-point scale. Results were analyzed with proportional odds models for ordinal credibility ratings. Results A total of 192 of 203 residents (95%), 72 faculty, and 10 SPs participated. For communication stations, odds of high credibility ratings were significantly lower for SP than for faculty examiners (odds ratio [OR] = 0.28, P < .001). For clinical stations, credibility odds were lower for specialty incongruent faculty (OR = 0.19, P < .001) and female faculty (OR = 0.45, P < .001). Conclusions Faculty examiners were perceived as being more credible than SP examiners, despite standardizing feedback delivery. Specialty incongruency with station content and female sex were associated with lower credibility ratings for faculty examiners.