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Background Given the increased need to enhance musculoskeletal education, an inaugural musculoskeletal (MSK) focused module was developed and evaluated as part of an orthopedic surgery training program at the University of Toronto. The educational offerings were based on a previously validated MSK Curriculum. Specifically, the aims are to evaluate the effectiveness of the module on 1) improving MSK knowledge and skills expected of graduating Orthopaedic residents and 2) the ability of residents to collaborate professionally with non-surgical MSK clinicians. Methods Nine residents initially selected to participate in the competency based curriculum for orthopaedic surgery completed this module as an essential component of their training. The module was experienced during the mid-point of training (PGY 3 equivalent). An evaluation template was developed using pre and post module multiple choice (MCQ) and short answer questions (SAQ) to assess knowledge; summary of in-training education reports (ITERs) of clinical educational experiences and; feedback obtained for scholarly presentations. Structured feedback was obtained from learners and educators to evaluate the effectiveness of the module and to inform changes to optimize future learning opportunities and environments. Results Nine residents completed the pilot study. The module was 8 weeks long. Learners rotated through clinical settings within five educational pillars. All residents demonstrated improvements in MSK medicine knowledge expected of graduating Orthopaedic residents with a 40% increase in mean MCQ scores (76% vs 60%; p

Purpose: Although the field of medical education research is growing and residents are increasingly recruited to participate as subjects in research studies, little is known about their experiences. The goal of this study was to explore the experiences and perceptions of residents who are study participants in medical education research. Method: A phenomenographic approach was chosen to examine the range of residents’ experiences as research participants. A maximum variation sampling strategy was used to identify residents with diverse experiences. Semi-structured interviews that explored experiences as research participants were conducted with nineteen residents in internal medicine, general surgery, and pediatrics at the University of Toronto in 2015–2016. Results: The perceptions and experiences of participants fell into two categories. First, participation was seen as a professional responsibility to advance the profession, including a desire to improve future educational practices and a sense of responsibility to contribute to the academic cause. Second, the experience was noted for its personal impact, including benefits (e.g., receiving monetary incentives or novel educational experiences) and risks (e.g., coercion and breaches of confidentiality). The time required to participate in a study was identified as one of the most important factors affecting willingness to participate and the impact of participation. Conclusions: Being a participant in medical education research can be perceived in different ways. Understanding the view of resident participants is important to optimize potential benefits and minimize risks and negative consequences for them, thus fostering ready participation and high-quality research.

Background Residents' attitudes toward error disclosure have improved over time. It is unclear whether this has been accompanied by improvements in disclosure skills. Objective To measure the disclosure skills of internal medicine (IM), paediatrics, and orthopaedic surgery residents, and to explore resident perceptions of formal versus informal training in preparing them for disclosure in real-world practice. Methods We assessed residents' error disclosure skills using a structured role play with a standardized patient in 2012–2013. We compared disclosure skills across programs using analysis of variance. We conducted a multiple linear regression, including data from a historical cohort of IM residents from 2005, to investigate the influence of predictor variables on performance: training program, cohort year, and prior disclosure training and experience. We conducted a qualitative descriptive analysis of data from semistructured interviews with residents to explore resident perceptions of formal versus informal disclosure training. Results In a comparison of disclosure skills for 49 residents, there was no difference in overall performance across specialties (4.1 to 4.4 of 5, P = .19). In regression analysis, only the current cohort was significantly associated with skill: current residents performed better than a historical cohort of 42 IM residents (P Conclusions Residents across specialties have similar skills in disclosure of errors. Residents identified role modeling and a strong local patient safety culture as key facilitators for disclosure.

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 resident's 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 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.

Background Concern surrounding the effect of resident fatigue on patient care recently led the National Steering Committee on Resident Duty Hours to publish Canadian recommendations suggesting that duty periods of 24 or more consecutive hours without restorative sleep should be avoided. We sought to characterize how different training programs are preparing for the effect of such changes on education, patient care and provider well-being. Methods Using constructivist grounded theory methodology, we conducted 18 one-on-one semistructured interviews with program directors, division directors and department chiefs from 11 residency programs affiliated with one Canadian medical school. We gathered and analyzed data iteratively until we reached theoretical saturation. Results The key theme articulated by our participants was that changes in resident duty hours would potentially lead to gaps in the provision of clinical care. These changes affect acute care specialties based primarily in the inpatient setting (e.g., medicine, surgery) more than primarily ambulatory (e.g., family medicine) or shift-model based (e.g., emergency) specialties. Potential strategies to address gaps in clinical care include resident-based solutions, faculty-based solutions and solutions based on other providers (e.g., nonacademic physicians, physician extenders). Each solution has unique advantages and disadvantages in terms of education, continuity of care, preparedness for practice and provider well-being. Interpretation Our data-driven framework serves as a guide for programs to anticipate challenges of satisfying clinical care needs in the face of changes to resident duty hours, while balancing education, care continuity, preparedness for practice and provider well-being. Our findings challenge the "one-size-fits-all" approach to changes to resident duty hours and endorse flexibility in enacting duty hour regulations based on specialty-specific factors.

Objective.The effect of systemic sclerosis (SSc) on bone density is not well understood. Through systematic review of the literature, the objectives of this study were to synthesize data about the prevalence of low bone mineral density (BMD), risk factors for low BMD, and occurrence of fracture and fracture-related mortality in SSc.Methods.A search was conducted of MEDLINE (1948–2012), Evidence Based Medicine Reviews (1991–2012), EMBASE (1980–2012), and CINAHL (1981–2012). Abstracts were screened to identify studies that evaluated low BMD in patients with SSc. Two investigators independently used a standardized form to abstract prevalence of osteopenia and osteoporosis (OP); risk factors for low BMD, BMD measurements, frequency of fracture, and fracture-related mortality.Results.Screening of 1032 citations identified 19 articles. Fifteen studies compared patients with SSc to controls. Most patients were white, female (prevalence 74%–100%), and postmenopausal (prevalence 45.9%–100%). The prevalence of low BMD and OP was 27%–53.3% and 3%–51.1%, respectively. Ten studies reported a lower BMD in patients with SSc compared to matched controls, whereas 2 studies reported no difference. Candidate risk factors for low BMD in SSc include family history of OP, age, menopause, diffuse subtype, presence of internal organ involvement, low vitamin D levels, and calcinosis. However, the studies supporting these factors were conflicting. Fracture rate ranged between 0% and 38%. No study reported OP-related fracture mortality.Conclusion.The data suggest that patients with SSc are at risk of low BMD and fracture, especially when other risk factors for OP are present. The interaction of SSc manifestations, traditional OP risk factors, and clinically relevant outcomes is complex and warrants further research.

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.

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.

Objective.To determine the proportion of patients with early inflammatory arthritis in a Canadian cohort who are at high risk for a major osteoporotic fracture using the Fracture Risk Assessment Tool (FRAX®), and to determine if a care gap exists in high-risk patients.Methods.FRAX was applied to 238 patients enrolled in the Canadian Early Arthritis Cohort (CATCH) study based on norms from the United States and the United Kingdom, without the use of bone mineral density measurements.Results.FRAX identified 5%–13% of patients at high risk for fracture, using a conservative analysis. Based on US norms, there was a significant correlation between increasing fracture risk groups and oral glucocorticoid use (p = 0.012) and baseline erosions (p = 0.040). Calcium or vitamin D use did not vary among the different fracture risk groups (p = NS), nor did bisphosphonate use (p = NS). The Disease Activity Score with 28 joint count in the high-risk group was significantly higher compared to the low-risk group (p = 0.048).Conclusion.Patients at increased risk had higher disease activity, more frequent glucocorticoid use, and more baseline erosions compared to patients at low risk. A care gap exists, in that a very low proportion of patients at high risk are being treated with calcium, vitamin D, and/or bisphosphonates. A higher fracture risk was calculated in our cohort using the US FRAX calculation tool compared to the UK calculation tool. These data highlight the need to identify and modify fracture risk in patients with early inflammatory arthritis.

Background Immunologic mechanisms play an integral role in understanding the pathogenesis and management of rheumatic conditions. Currently, there is limited access to formal instruction in immunology for rheumatology trainees across Canada. Aim The aims of this study were (1) to describe current immunology curricula among adult rheumatology training programs across Canada and (2) to compare the perceived learning needs of rheumatology trainees from the perspective of program directors and trainees to help develop a focused nationwide immunology curriculum. Methods Rheumatology trainees and program directors from adult rheumatology programs across Canada completed an online questionnaire and were asked to rank a comprehensive list of immunology topics. A modified Delphi approach was implemented to obtain consensus on immunology topics. Results Only 42% of program directors and 31% of trainees felt the current method of teaching immunology was effective. Results illustrate concordance between program directors and trainees for the highest-ranked immunology topics including innate immunity, adaptive immunity, and cells and tissues of the immune system. However, there was discordance among other topics, such as diagnostic laboratory immunology and therapeutics. Conclusions There is a need to improve immunology teaching in rheumatology training programs. Results show high concordance between the basic immunology topics. This study provides the groundwork for development of future immunology curricula.

Introduction: Formative assessment requires effective feedback. Recent studies have demonstrated the importance of considering the learner's perspective as a determinant of feedback effectiveness. Objective: We examined factors affecting residents' perceptions of the credibility of their examiners/feedback providers during a formative OSCE, including examiner demographics. Methods: Following a formative 5-station internal medicine OSCE, residents were randomized to receive feedback with or without scores, and then asked to fill a questionnaire rating the credibility of feedback providers on their final station. Feedback was provided by clinical faculty or standardized patients (SPs). Residents also rated the quality and characteristics of the feedback received, and previous knowledge of examiner. Correlations between feedback characteristics were explored and predictors of credibility were examined through multivariable linear regression. Results: 180 residents participated in the OSCE. Mean credibility of examiners was 4.37 of 5 (with 89% ≥ 4). Credibility was somewhat lower for SP raters compared to faculty, but differences were not significant (4.09 versus 4.41, P = .47). Rater and learner demographic variables did not affect credibility on multivariable analysis; however, the following feedback characteristics were significant predictors of credibility: specificity and balance between positive and formative comments. Provision of scores, actual or perceived resident score on station, length of feedback, and pacing did not appear to affect credibility. Perceived quality of feedback was strongly correlated with credibility. Conclusions: Residents rated the credibility of feedback providers highly in this formative OSCE. Characteristics of raters did not affect credibility. Feedback format, including specificity and balance, were associated with higher feedback credibility.

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.

To evaluate the impact of a formal mentoring program on time to academic promotion and differences in gender-based outcomes.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.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.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.

Objectives To report a patient with aortic regurgitation (AR) and aortitis, who failed to respond to multiple attempts at surgical replacement of the affected valve and adjacent aorta, and in whom a late diagnosis of spondyloarthritis (SpA) was made. The relevant literature on the association of SpA and aortitis is reviewed. Methods Descriptive case report of a patient with AR secondary to aortic dilation and aortitis with a late diagnosis of SpA, and a review of the relevant literature (PubMed search 1956 through April 2008). Results A 36-year-old man was admitted to the hospital for replacement of his aortic valve and aortic valve root as a result of AR after a dehiscence of a mechanical prosthetic valve and subsequent aortic pseudoaneurysm. His past medical history included 2 prior aortic valve replacements that failed due to late postoperative dehiscence. Histological findings from the aortic wall after the third operation showed signs of aortitis. A rheumatologic workup revealed a 6-year history of mild low back pain, radiological evidence of bilateral sacroiliitis, and presence of HLA-B27. A diagnosis of SpA, most likely ankylosing spondylitis (AS), was made. On reviewing the literature, AR has been diagnosed in 2 to 12% of the patients with AS, most of whom had long-lasting disease. There have been several reports of uncommon presentations of acute AR in young patients with juvenile AS; however, no similar adult case was found. Conclusion This unusual case emphasizes the importance of early and adequate workup for SpA in young patients with lone AR or aortic dilation.

Philip Seo, with Alan Hakim, Gavin Clunie, and Inam Haq. Oxford: Oxford University Press, 2013, 624 pages, $53 US The Oxford American Handbook of Rheumatology (2nd Edition) is a pocket-size reference guide to the diagnosis and management of a wide spectrum of rheumatologic disorders. The Handbook is divided into 2 major sections. The first focuses on the approach to and differential diagnosis of overarching concepts in rheumatology, …

BACKGROUND Comments on residents' in-training evaluation reports (ITERs) may be more useful than scores in identifying trainees in difficulty. However, little is known about the nature of comments written by internal medicine faculty on residents' ITERs. METHOD Comments on 1,770 ITERs (from 180 residents in postgraduate years 1-3) were analyzed using constructivist grounded theory beginning with an existing framework. RESULTS Ninety-three percent of ITERs contained comments, which were frequently easy to map onto traditional competencies, such as knowledge base (n = 1,075 comments) to the CanMEDs Medical Expert role. Many comments, however, could be linked to several overlapping competencies. Also common were comments completely unrelated to competencies, for instance, the resident's impact on staff (813), or personality issues (450). Residents' "trajectory" was a major theme (performance in relation to expected norms [494], improvement seen [286], or future predictions [286]). CONCLUSIONS Faculty's assessments of residents are underpinned by factors related and unrelated to traditional competencies. Future evaluations should attempt to capture these holistic, integrated impressions.

Introduction Ankylosing 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. Methods Patients 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). Results The 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. Conclusions Patients 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.