Pulse
Rheumatology 2.0
Then Anne Minenko, M.D., was put in charge of the University of Minnesota’s elective in rheumatology in 2000, she found that only a handful of medical students and residents were selecting it, and those who did were not going on to do further training in the subspecialty she loved.
Not only was she concerned that more trainees wouldn’t learn how to do a joint exam or manage basic rheumatic diseases, the assistant professor was worried about the future of her subspecialty. If new talent wasn’t recruited, soon more rheumatologists would be retiring than entering the specialty—and this at a time when patients were getting older and in need of care for diseases such as arthritis. Indeed, a study commissioned by the American College of Rheumatology has projected that the nation could be short nearly 2,600 rheumatologists by 2025 if the current trend continues.
So Minenko started looking for ways to make the elective more attractive. “We wanted to appeal to students, to get them to see what is possible, to come and experience the professional fulfillment of taking care of patients with rheumatic conditions,” she says. She also wanted to communicate that rheumatology was not just about osteoarthritis and aspirin. It was about helping patients orchestrate medications as sophisticated as chemotherapy to nip inflammation in the bud and alter the course of an aberrant immune system before it destroyed organs. Like any good product designer, she’s made a series of changes.
No. 1 Cause of Disability
Arthritis is the leading cause of disability amoung U.S. adults, according to an article published in the Morbidity and Mortality Weekly Report in May. Arthritis or rheumatism affect 19 percent of the total population (8.6 million people) and 24.3 percent of women. Back or spine problems are the second most common cause, affecting 7.6 million people; heart trouble is the third, affecting 3 million. Disability costs an estimated $300 million annually. The findings were based on the 2005 Survey of Income and Program Participation.
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The first was to add a three-hour lesson on how to do a joint exam using a standardized or “trained” patient. Patients in pain, she notes, are not always enthusiastic about having someone learn such skills on them. They want doctors who are proficient and efficient, and they want their questions (not the medical students’) answered. By using a mock patient, Minenko could take the time to explain from an anatomical perspective why she pushed and prodded on joints the way she did. She says one of the most common difficulties students have is learning to detect fluid in the knee. “They don’t make the connection between what’s underneath the skin with what’s on top of the skin,” she says. For example, they forget that the knee joint includes communicating compartments. Fluid may be hidden in one compartment, and the only way to discover it is to push there to see if it displaces and surfaces in another.
The next change was to purchase a set of latex “limbs”— elbows, shoulders, and knees—that were specially wired to give students feedback on their exam or on their ability to aspirate a joint. “It’s like the old game Operation,” she says, noting that a red light alerts students if they’ve done something wrong and a green one gives them positive feedback. The most recent upgrade to the course is a series of online learning modules. Working with the university’s Digital Media Center, Minenko has created a module that reviews the joint exam and others that expose students to rarer rheumatologic cases than they might encounter during their three weeks in the clinic. Students are asked about the cases, then get immediate feedback on their answers.
Minenko says that since she’s made the changes, students are more enthusiastic about the elective. There’s someone signed up nearly every month. In addition, there has been an uptick in the number of University of Minnesota residents who have chosen to pursue rheumatology as a subspecialty. Although she hesitates to credit her efforts for this, she acknowledges that the trend is in the right direction. “We’re on a good streak,” she says.—Carmen Peota