Rheumatology

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Task

1. ●[select all that apply] rheumatologic history
2. ●MSK exam (physical)

Exam techniques

1. ●[select all that apply] small joint (MCP, PIP, DIP, wrists, MTP)
2. ●large joint (knees, hips, ankles, shoulders, elbows)
3. ●peripheral and axial joint
4. ●not applicable

Medical Expert

• □Part A: ME 1.3 Apply knowledge of uncomplicated rheumatologic diseases and symptoms of extra-articular manifestations
• □Part A: ME 2.2 Elicit a history relevant to the rheumatologic presentation
• □Part A: ME 2.2 Perform a focused MSK physical exam using appropriate technique for joint examinations
• □Part A: ME 2.2 Focus the clinical encounter, performing it in a time-effective manner without excluding key elements
• □Part B: ME 2.2 Interpret findings of the MSK physical exam to differentiate between inflammatory and non-inflammatory pain
• □Part B: ME 2.2 Synthesize patient information from the clinical assessment for the purpose of written or verbal summary

Communicator

• □Part A: COM 2.1 Use patient-centred interviewing skills to effectively gather all relevant information
• □Part A: COM 2.2 Provide a clear structure for and manage the flow of the patient encounter
• □Part B: COM 2.1 Use patient-centred interviewing skills to effectively gather all relevant information
• □Part B: COM 5.1 Document the essential elements of a rheumatologic history and MSK physical examination using a structured approach

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Setting

1. ●inpatient
2. ●outpatient
3. ●emergency room
4. ●simulation
5. ●telephone

Case mix

1. ●[select all that apply] serious infections and conditions related to immune suppression
2. ●CTD emergency
3. ●vasculitis emergency
4. ●scleroderma emergency
5. ●suspected septic arthritis with synovial fluid interpretation
6. ●HLH/MAS

Medical Expert

• □ME 1.4 Recognize urgent problems that may need the involvement of more experienced colleagues and seek their assistance
• □ME 2.2 Focus the clinical encounter, performing it in a time-effective manner without excluding key elements
• □ME 2.2 Develop a differential diagnosis relevant to the patient’s presentation
• □ME 2.2 Select and/or interpret appropriate initial investigations
• □ME 2.4 Develop and implement plans for initial management

Collaborator

• □COL 1.3 Communicate effectively with physicians and other health care professionals
• □COL 3.1 Identify patients requiring handover to other physicians or health care professionals

Leader

• □L 2.1 Apply knowledge of local resources for optimal patient care

Professional

• □P 1.1 Exhibit appropriate professional behaviours

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Setting

1. ●inpatient
2. ●outpatient
3. ●emergency room
4. ●simulation

Case mix

1. ●inflammatory arthritis
2. ●systemic rheumatologic disease
3. ●non-inflammatory MSK condition
4. ●crystal arthritis

Medical Expert

• □ME 2.2 Elicit a history and perform a relevant physical exam
• □ME 2.2 Synthesize patient information to determine diagnosis
• □ME 2.2 Select and/or interpret appropriate investigations
• □ME 2.4 Develop management plans in the context of best evidence and guidelines
• □ME 1.4 Present clinical findings in an organized and well synthesized manner
• □ME 1.3 Apply knowledge of rheumatologic disease as it pertains to inflammatory arthritides, systemic rheumatologic diseases, and non- inflammatory MSK conditions
• □ME 2.2 Apply the clinical implication of test results, sensitivity/specificity, and pre- and post-test probabilities

Communicator

• □COM 2.1 Use patient-centred interviewing skills to effectively gather all relevant information
• □COM 5.1 Document clinical encounters to convey clinical reasoning and the rationale for decisions
• □COM 2.3 Seek and synthesize relevant information from other sources

Collaborator

• □COL 1.3 Communicate effectively with physicians and other health care professionals

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Setting

1. ●inpatient
2. ●outpatient
3. ●emergency room
4. ●simulation

Case mix

1. ●[select all that apply] serious infections and conditions related to immune suppression
2. ●SLE/APL emergency
3. ●GCA and systemic vasculitis emergency
4. ●scleroderma emergency
5. ●suspected septic arthritis with synovial fluid interpretation
6. ●HLH/MAS

Medical Expert

• □ME 2.1 Identify clinical emergencies and prioritize response
• □ME 1.4 Recognize urgent problems that may need the involvement of more experienced colleagues and seek their assistance
• □ME 2.2 Perform focused clinical assessments in a time-effective manner, without excluding key elements
• □ME 2.2 Select and/or interpret appropriate investigations
• □ME 2.4 Develop and implement plans for initial management
• □ME 4.1 Ensure follow-up on results of investigation and response to treatment
• □ME 4.1 Coordinate management plans with attending physicians and other health care professionals

Communicator

• □COM 2.3 Seek and synthesize relevant information from other sources
• □COM 5.1 Document clinical encounters to convey clinical reasoning and the rationale for decisions

Collaborator

• □COL 1.3 Communicate effectively with physicians and other health care professionals

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Joint

1. ●[select all that apply] shoulder
2. ●knee
3. ●hip

Case mix

1. ●established inflammatory arthritis
2. ●early inflammatory arthritis
3. ●axial SpA/JSpA
4. ●non-inflammatory MSK

Medical Expert

• □ME 1.3 Apply knowledge of MSK anatomy, including synovial membrane, joints, and soft tissue
• □ME 2.2 Perform the MSK examination in a focused, time-effective manner without excluding key elements
• □ME 2.2 Interpret the results of the MSK examination in the context of the patient’s presentation
• □ME 1.4 Present clinical findings in an organized and well synthesized manner

Communicator

• □COM 1.2 Optimize the physical environment for patient comfort, dignity, privacy, and safety
• □COM 5.1 Document the essential elements of an MSK examination, including abnormal findings

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Medical Expert

• □ME 3.1 Describe the indications and contraindications for knee arthrocentesis
• □ME 3.4 Determine and select sedation and local analgesia, as appropriate
• □ME 3.2 Obtain informed consent
• □ME 3.4 Gather and/or manage the availability of appropriate instruments and materials
• □ME 3.4 Prepare and position the patient for the procedure
• □ME 3.4 Demonstrate aseptic technique: skin preparation, establishing and respecting the sterile field
• □ME 3.4 Apply knowledge of anatomy, key landmarks and the procedure
• □ME 3.4 Execute the steps of the procedure in a safe and efficient manner
• □ME 2.2 Select appropriate fluid analysis
• □ME 3.4 Handle samples in a safe manner
• □ME 3.4 Optimize patient comfort and safety, including the need for analgesia, and modify the procedure as needed
• □ME 4.1 Provide discharge instructions and plan for follow-up
• □ME 3.4 Prevent and/or manage immediate complications of the procedure

Communicator

• □COM 5.1 Document the encounter to convey the procedure and outcome

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Medical Expert

• □ME 3.1 Describe the indications and contraindications for knee arthrocentesis
• □ME 3.4 Determine and select sedation and local analgesia, as appropriate
• □ME 3.2 Obtain informed consent
• □ME 3.4 Gather and/or manage the availability of appropriate instruments and materials
• □ME 3.4 Prepare and position the patient for the procedure
• □ME 3.4 Demonstrate aseptic technique: skin preparation, establishing and respecting the sterile field
• □ME 3.4 Apply knowledge of anatomy, key landmarks and the procedure
• □ME 3.4 Execute the steps of the procedure in a safe and efficient manner
• □ME 2.2 Select appropriate fluid analysis
• □ME 3.4 Handle samples in a safe manner
• □ME 3.4 Optimize patient comfort and safety, including the need for sedation and/or analgesia and modify the procedure as needed
• □ME 4.1 Provide discharge instructions and plan for follow-up
• □ME 3.4 Prevent and/or manage immediate complications of the procedure

Communicator

• □COM 5.1 Document the encounter to convey the procedure and outcome

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Issue

1. ●[select all that apply] diagnosis, non-pharmacologic intervention
2. ●prednisone
3. ●NSAIDs

Medical Expert

• □ME 1.3 Apply knowledge of clinical pharmacology as it relates to therapeutic agents in rheumatologic disease
• □ME 3.1 Describe the indications, contraindications, and potential side-effects for NSAID and non-pharmacologic therapies
• □ME 3.1 Describe the alternatives for a given procedure or therapy

Communicator

• □COM 1.1 Communicate using a patient-centred approach that encourages patient trust and autonomy
• □COM 1.6 Assess a patient’s decision-making capacity
• □COM 3.1 Convey the diagnosis and treatment in a clear and compassionate manner
• □COM 3.1 Share information and explanations that are clear and accurate while checking for understanding
• □COM 1.3 Recognize the values, biases, or perspectives of patients and modify the approach to the patient accordingly
• □COM 4.2 Assist patients and their families to identify, access, and make use of information and communication technologies to support their care and manage their health

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Document

1. ●new patient letter
2. ●follow up letter
3. ●new consultation request

Medical Expert

• □Part A: ME 2.2 Synthesize and interpret information from the clinical assessment
• □Part A: ME 2.2 Interpret clinical information, along with the results of investigations, for the purposes of diagnosis and management
• □Part A: ME 2.4 Develop recommendations for management that address the consult question
• □Part B: ME 2.2 Interpret clinical information, along with the results of investigations, for the purposes of diagnosis and management
• □Part B: ME 1.3 Apply knowledge of clinical pharmacology as it pertains to therapeutic agents in rheumatologic disease
• □Part B: ME 2.4 Adapt dosing recommendations for patient’s condition and body size and/or drug elimination route, as relevant
• □Part B: ME 5.2 Apply strategies for risk mitigation when prescribing medications with significant adverse effects (e.g. bisphosphonates with steroids)
• □Part B: ME 4.1 Monitor for medication toxicity and/or response to treatment
• □Part B: ME 5.2 Select duration of medication supply based on risk of toxicity and/or non-adherence

Communicator

• □Part A: COM 5.1 Organize information in appropriate sections
• □Part A: COM 5.1 Document all relevant findings and investigations
• □Part A: COM 5.1 Convey clinical reasoning and the rationale for decisions
• □Part A: COM 5.1 Provide a clear plan for ongoing management
• □Part A: COM 5.1 Complete clinical documentation in a timely manner
• □Part B: COM 5.1 Write prescriptions legibly and clearly, with attention to atypical dosing and frequency

Collaborator

• □Part A: COL 1.3 Share expertise when acting in the consultant role, using referral as an opportunity to improve quality of care

Professional

• □Part B: P 3.1 Demonstrate knowledge of professional standards related to documentation of prescriptions

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Setting

1. ●inpatient
2. ●ICU
3. ●emergency room
4. ●ambulatory

Case mix

1. ●chronic inflammatory MSK condition
2. ●acute arthritis
3. ●non-inflammatory MSK condition
4. ●systemic rheumatologic disease
5. ●widespread chronic pain syndrome

Medical Expert

• □ME 1.3 Apply clinical and biomedical knowledge to manage the breadth of rheumatologic presentations
• □ME 1.4 Perform clinical assessments that address all relevant issues
• □ME 2.2 Elicit a history and perform a physical exam, identifying extra- articular manifestations
• □ME 2.2 Perform comprehensive medical record reviews
• □ME 2.2 Synthesize patient information to determine diagnosis
• □ME 2.2 Select and/or interpret appropriate investigations
• □ME 2.2 Interpret the results of plain radiographs in the context of the patient’s presentation
• □ME 2.4 Develop and implement management plans including both non- pharmacologic and pharmacologic modalities, as appropriate
• □ME 4.1 Establish plans for monitoring the patient’s condition and medication side effects

Communicator

• □COM 2.3 Seek and synthesize relevant information from other sources
• □COM 5.1 Document clinical encounters to convey clinical reasoning and the rationale for decisions

Collaborator

• □COL 1.2 Consult as needed with other health care professionals, including other physicians

Leader

• □L 2.2 Apply evidence and guidelines with respect to resource utilization

Health Advocate

• □HA 1.1 Facilitate timely patient access to services and resources

Scholar

• □S 3.4 Integrate best evidence and clinical expertise into decision-making

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Joint

1. ●hip
2. ●foot and ankle
3. ●elbow
4. ●hand and wrist
5. ●neck exam
6. ●back exam

Joint count

1. ●yes
2. ●no

Extra-articular manifestations

1. ●[write in] not applicable
2. ●skin
3. ●eyes
4. ●GI
5. ●enthesitis
6. ●tenosynovitis
7. ●other

Medical Expert

• □ME 1.3 Apply knowledge of MSK anatomy, including synovial membrane, joints, and soft tissue
• □ME 1.3 Apply clinical knowledge of rheumatologic diseases and associated extra- articular manifestations
• □ME 2.2 Apply physical examination maneuvers to assess and diagnose rheumatologic disease
• □ME 2.2 Perform an MSK exam, identifying abnormal findings
• □ME 2.2 Perform the MSK examination in a focused, time-effective manner without excluding key elements
• □ME 2.2 Perform a comprehensive joint count for tender joints
• □ME 2.2 Perform a comprehensive joint count for swollen joints
• □ME 2.2 Apply and integrate evidence with respect to standard disease activity measures

Communicator

• □COM 1.2 Optimize the physical environment for patient comfort, dignity, privacy, and safety
• □COM 5.1 Document clinical encounters in an accurate, complete, clear, and timely manner

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Setting

1. ●inpatient
2. ●outpatient
3. ●emergency room
4. ●simulation

Procedure

1. ●aspiration (dry aspirate acceptable)
2. ●injection (no ultrasound)
3. ●both

Anatomy

1. ●shoulder
2. ●elbow
3. ●wrist
4. ●ankle
5. ●small joint (MCP, MTP, IP or CMC)

Injection site

1. ●none
2. ●soft tissue (carpal tunnel, bursae (trochanteric, anserine, subacromial))
3. ●tendons (DeQuervain’s, trigger fingers, dactylitis)
4. ●plantar fasciitis

Medical Expert

• □Part A: ME 3.2 Obtain informed consent for the procedure and therapy
• □Part A: ME 3.2 Describe the indications and contraindications for the procedure
• □Part A: ME 3.4 Gather and assess required information prior to the procedure
• □Part A: ME 3.4 Gather and/or manage the availability of appropriate instruments and materials
• □Part A: ME 3.4 Prepare and position the patient for the procedure
• □Part A: ME 3.4 Apply knowledge of anatomy, key landmarks and the procedure
• □Part A: ME 3.4 Demonstrate aseptic technique: skin preparation, establishing and respecting the sterile field
• □Part A: ME 3.4 Execute the steps of the procedure in a safe and efficient manner
• □Part A: ME 2.2 Select appropriate fluid analysis
• □Part A: ME 3.4 Optimize patient comfort and safety, including need for analgesia, and modify the procedure as needed
• □Part A: ME 4.1 Provide discharge instructions and plan for follow-up
• □Part A: ME 3.4 Prevent and/or manage immediate complications of the procedure
• □Part B: ME 3.4 Identify normal and abnormal findings using a polarized microscope

Communicator

• □Part A: COM 5.1 Document the encounter to convey the procedure and outcome
• □Part B: COM 5.1 Document all relevant findings

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Setting

1. ●inpatient
2. ●outpatient
3. ●emergency room
4. ●simulation

Case mix

1. ●aspiration (dry aspirate acceptable)
2. ●injection (no ultrasound)
3. ●both

Anatomy

1. ●shoulder
2. ●elbow
3. ●wrist
4. ●ankle
5. ●MCP/MTP
6. ●subtalar
7. ●PIP/DIP
8. ●IP (thumb/ toe)

Medical Expert

• □Part A: ME 3.2 Obtain informed consent for the procedure and therapy
• □Part A: ME 3.2 Describe the indications and contraindications for the procedure
• □Part A: ME 3.4 Gather and assess required information prior to the procedure
• □Part A: ME 3.4 Gather and/or manage the availability of appropriate instruments and materials
• □Part A: ME 3.4 Prepare and position the patient for the procedure
• □Part A: ME 3.4 Apply knowledge of anatomy, key landmarks and the procedure
• □Part A: ME 3.4 Demonstrate aseptic technique: skin preparation, establishing and respecting the sterile field
• □Part A: ME 3.4 Execute the steps of the procedure in a safe and efficient manner
• □Part A: ME 2.2 Select appropriate fluid analysis
• □Part A: ME 3.4 Optimize patient comfort and safety, including need for sedation and/or analgesia, and modify the procedure as needed
• □Part A: ME 4.1 Provide discharge instructions and plan for follow-up
• □Part A: ME 3.4 Prevent and/or manage immediate complications of the procedure
• □Part B: ME 3.4 Identify normal and abnormal findings using a polarized microscope

Communicator

• □Part A: COM 5.1 Document the encounter to convey the procedure and outcome
• □Part B: COM 5.1 Document all relevant findings

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Case mix

1. ●[select all that apply] chronic inflammatory axial MSK condition
2. ●chronic inflammatory peripheral MSK condition
3. ●systemic rheumatologic disease
4. ●SLE
5. ●vasculitis
6. ●myositis
7. ●Sjögren’s
8. ●scleroderma/morphea

Comorbidities

1. ●[select all that apply] none
2. ●anticoagulation issues
3. ●multiple comorbid diseases
4. ●extra-articular manifestations of rheumatologic disease
5. ●chronic liver disease
6. ●chronic kidney disease
7. ●child bearing age with preconception consideration
8. ●pregnancy
9. ●malignancy
10. ●significant social barriers to health care
11. ●cultural, language and/or religious barriers to communication and/or care
12. ●pre-op

Medical Expert

• □ME 1.4 Perform clinical assessments that address all relevant issues
• □ME 1.3 Apply knowledge of physiology and pathophysiology of chronic rheumatologic disease and its progression
• □ME 2.1 Iteratively establish priorities, considering the perspective of the patient and family (including values and preferences) as the patient’s situation evolves
• □ME 2.2 Select and interpret rheumatologic investigations, including plain radiography
• □ME 2.2 Assess medication adherence, response to therapy and adverse effects
• □ME 2.3 Establish goals of care, which may include slowing disease progression, improving function or palliation
• □ME 2.4 Develop and implement management plans including both non- pharmacologic and pharmacologic modalities, as appropriate
• □ME 4.1 Implement a plan for ongoing care, follow-up on investigations, response to treatment and monitoring for disease progression

Communicator

• □COM 1.6 Adapt communication to the unique needs and preferences of the patient
• □COM 3.1 Share information and explanations that are clear and accurate while checking for understanding

Health Advocate

• □HA 1.2 Recognize potential barriers such as illness, health literacy, cultural practice/beliefs and language skills
• □HA 1.2 Select patient education resources related to rheumatology
• □HA 1.2 Work with patients to increase their understanding of their condition and associated comorbidities, supporting their active role in their disease management

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Diagnosis

1. ●[select all that apply] chronic inflammatory MSK condition
2. ●SLE
3. ●vasculitis
4. ●PMR
5. ●gout
6. ●infection related
7. ●medication side effect
8. ●disease flares

Anatomic site

1. ●[select all that apply] axial
2. ●peripheral
3. ●non-articular

Medical Expert

• □ME 1.3 Apply knowledge of physiology and pathophysiology of chronic rheumatologic disease and its progression
• □ME 1.4 Perform clinical assessments that address all relevant issues
• □ME 1.6 Adapt care as the complexity and uncertainty of the patient’s clinical situation evolves
• □ME 1.6 Seek assistance in situations that are new or complex
• □ME 2.1 Prioritize which issues need to be addressed
• □ME 2.3 Establish goals of care, which may include slowing disease progression, improving function or palliation
• □ME 2.2 Interpret the results of investigations identifying disease progression, activity, and complications
• □ME 2.2 Interpret the results of investigations identifying complications from treatment
• □ME 2.2 Synthesize and interpret information from the clinical assessment
• □ME 2.2 Determine the severity and/or stage of the patient’s condition, activity of disease, and risk of progression
• □ME 2.4 Develop and implement management plans including both non- pharmacologic and pharmacologic modalities, as appropriate
• □ME 1.3 Apply knowledge of clinical pharmacology as it relates to therapeutic agents in rheumatologic disease
• □ME 4.1 Prevent and/or manage complications of chronic rheumatologic diseases
• □ME 3.1 Identify indications, timing and suitable non-pharmacologic and pharmacologic therapies
• □ME 3.3 Triage procedures or therapies taking into account clinical urgency and potential for deterioration
• □ME 1.3 Apply knowledge of the risks and benefits of therapeutic options in rheumatologic disease

Communicator

• □COM 3.1 Provide information on diagnosis and/or prognosis clearly and compassionately

Health Advocate

• □HA 1.1 Work with patients to identify and implement strategies for health promotion

Professional

• □P 1.1 Respond punctually to requests from patients or other health care professionals
• □P 1.1 Exhibit appropriate professional behaviors

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Type of observation

1. ●consult note/written communication
2. ●case discussion

Medical Expert

• □ME 1.6 Recognize and respond to the complexity, uncertainty, and ambiguity inherent in medical practice
• □ME 2.2 Synthesize and interpret information from the clinical assessment
• □ME 2.2 Revise the differential diagnosis in response to new clinical information, or response to treatment
• □ME 2.4 Demonstrate flexibility in clinical reasoning, in the setting of clinical uncertainty
• □ME 2.4 Establish a patient centred management plan despite limited, non- diagnostic, or conflicting clinical data

Communicator

• □COM 3.1 Convey information related to the uncertainty in diagnosis and/or treatment in a clear, timely and transparent manner
• □COM 4.1 Use communication skills and strategies that help the patient make informed decisions
• □COM 5.1 Document clinical encounters to convey clinical reasoning and the rationale for decisions

Health Advocate

• □HA 1.2 Recognize potential barriers such as illness, health literacy, cultural practice/belief and language skills

Scholar

• □S 3.3 Critically evaluate the integrity, reliability, and applicability of health-related research and literature
• □S 3.4 Integrate best evidence and clinical expertise into decision-making

Professional

• □P 1.1 Identify limits in their own expertise

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Diagnosis

1. ●IA/JIA
2. ●CTD
3. ●vasculitis
4. ●uncertain diagnosis
5. ●chronic non-inflammatory pain
6. ●other [open text]

Medical Expert

• □Part A: ME 4.1 Establish plans for ongoing care
• □Part B: ME 3.2 Apply knowledge of the indications and contraindications , and positive and adverse effects of biologics or DMARD medications
• □Part B: ME 4.1 Implement a plan for monitoring and adjusting biologics or DMARD medication prescriptions and treatment plans
• □Part B: ME 4.1 Establish plans for ongoing care

Communicator

• □Part A: COM 1.1 Communicate using a patient-centred approach that encourages patient trust and autonomy
• □Part A: COM 1.5 Recognize when strong emotions are affecting an interaction and respond appropriately
• □Part A: COM 1.6 Tailor approaches to decision-making to patient capacity, values and preferences
• □Part A: COM 3.1 Share information and explanations that are clear and accurate while checking for understanding
• □Part A: COM 3.1 Provide information on diagnosis and/or prognosis clearly and compassionately
• □Part B: COM 1.1 Communicate using a patient-centred approach that encourages patient trust and autonomy
• □Part B: COM 1.5 Recognize when strong emotions are affecting an interaction and respond appropriately
• □Part B: COM 1.6 Tailor approaches to decision-making to patient capacity, values and preferences
• □Part B: COM 3.1 Share information and explanations that are clear and accurate while checking for understanding
• □Part B: COM 4.1 Use communication skills and strategies that help the patient make informed decisions

Leader

• □Part A: L 1.2 Contribute to a culture that promotes patient safety
• □Part B: L 1.2 Contribute to a culture that promotes patient safety

Health Advocate

• □Part A: HA 1.1 Identify barriers to access in the health care and social service system for individual patients
• □Part A: HA 1.3 Incorporate prevention, health promotion and health surveillance into patient interactions
• □Part B: HA 1.1 Identify barriers to access in the health care and social service system for individual patients
• □Part B: HA 1.3 Incorporate prevention, health promotion and health surveillance into patient interactions

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Documentation type

1. ●[select all that apply] new patient letter
2. ●follow up letter
3. ●inpatient notes
4. ●complex prescription

Prescription type

1. ●not applicable
2. ●DMARD (biologic)
3. ●complex/intravenous immunosuppressive medication

Complex case

1. ●yes
2. ●no

Medical Expert

• □ME 2.2 Synthesize and interpret information from the clinical assessment
• □ME 2.4 Develop recommendations for management that address the consult question and consider the patient’s status and other health problems

Communicator

• □COM 5.1 Organize information in appropriate sections
• □COM 5.1 Document all relevant findings and investigations
• □COM 5.1 Document clinical encounters to convey clinical reasoning and the rationale for decisions
• □COM 5.1 Provide a clear plan for ongoing management of complex patient presentations
• □COM 5.1 Use language and terminology that is clear, succinct, accurate and respectful

Collaborator

• □COL 1.3 Provide written documentation in a timely manner
• □COL 1.3 Share expertise when acting in the consultant role, using referral as an opportunity to improve quality of care

Professional

• □P 3.1 Adhere to professional standards related to documentation of prescriptions

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Medical Expert

• □ME 1.4 Perform relevant clinical assessments in a time-effective manner
• □ME 3.1 Determine the most appropriate procedures or therapies for the purpose of assessment and/or management
• □ME 4.1 Coordinate investigation, treatment and follow-up when multiple physicians and health care professionals are involved

Communicator

• □COM 5.1 Document clinical encounters in an accurate, complete, timely and accessible manner

Collaborator

• □COL 1.3 Use referral and consultation as opportunities to improve quality of care
• □COL 3.2 Provide safe handover of care during patient transition out of the hospital setting
• □COL 2.1 Show respect toward other health professionals
• □COL 1.3 Communicate effectively with physicians and other health care professionals

Leader

• □L 2.1 Allocate health care resources for optimal patient care
• □L 4.1 Set priorities and manage time to fulfil diverse responsibilities including clinical, administrative, supervisory and teaching responsibilities

Health Advocate

• □HA 1.1 Facilitate timely patient access to services and resources

Scholar

• □S 3.4 Integrate best evidence and clinical expertise into decision-making
• □S 2.3 Balance supervision and graduated responsibility, ensuring the safety of patients and learners
• □S 2.1 Recognize the influence of role-modelling and the impact of the formal, informal, and hidden curriculum on learners

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Medical Expert

• □ME 1.5 Prioritize patients based on the urgency of clinical presentations
• □ME 1.4 Perform relevant clinical assessments in a time-effective manner
• □ME 2.2 Select investigation strategies demonstrating awareness of availability and access in the outpatient setting
• □ME 2.4 Formulate evidence-based treatment plans that are suitable for implementation in the outpatient setting

Communicator

• □COM 5.1 Document clinical encounters to convey clinical reasoning and the rationale for decisions

Collaborator

• □COL 1.3 Address the questions and concerns of the referring/primary care physician when acting in the consultant role
• □COL 1.3 Use referral and consultation as opportunities to improve quality of care
• □COL 2.1 Delegate tasks and responsibilities in an appropriate and respectful manner

Leader

• □L 4.2 Manage clinic scheduling
• □L 4.1 Manage time effectively to maintain clinic flow
• □L 4.1 Review and act on test results in a timely manner

Professional

• □P 1.2 Prepare for clinical responsibilities, reviewing the list of planned patient visits
• □P 1.1 Respond punctually to requests from patients or other health care professionals
• □P 1.1 Exhibit appropriate professional behaviors

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Type of activity

1. ●journal club
2. ●rounds
3. ●academic half day
4. ●other

Leader

• □Part B: L 4.1 Integrate supervisory and teaching responsibilities into the overall management of the clinical service

Scholar

• □Part A: S 2.4 Develop learning objectives for a teaching activity
• □Part A: S 3.3 Critically evaluate the integrity, reliability and applicability of health related research and literature
• □Part A: S 2.4 Present the information in an organized manner to facilitate understanding
• □Part A: S 2.4 Use audiovisual aids effectively
• □Part A: S 2.4 Provide adequate time for questions and discussion
• □Part B: S 2.1 Use strategies for deliberate, positive role-modelling
• □Part B: S 2.2 Create a positive and safe learning environment for all members of the team
• □Part B: S 2.3 Balance supervision and graduated responsibility, ensuring the safety of patients and learners
• □Part B: S 3.4 Integrate best evidence and clinical expertise
• □Part B: S 2.5 Provide feedback to enhance learning and performance

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Medical Expert

• □ME 1.3 Apply knowledge of common rheumatologic disease as it pertains to pediatric patients
• □ME 1.4 Recognize urgent problems that may need the involvement of more experienced colleagues and seek their assistance
• □ME 4.1 Assess the need, timing, risk and benefits of referring a patient to another health professional and/or care setting
• □ME 2.2 Elicit a history relevant to the pediatric rheumatologic presentation
• □ME 2.2 Perform a focused MSK exam using appropriate technique for joint examinations in pediatrics
• □ME 2.2 Adapt the clinical assessment to the child’s age and development
• □ME 2.2 Select and interpret appropriate investigations in the context of the child’s age
• □ME 2.4 Determine the setting of care appropriate for the patient’s health needs

Communicator

• □COM 2.3 Seek and synthesize relevant information from other sources
• □COM 3.1 Share information and explanations that are clear and accurate while checking for understanding

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Type of observation

1. ●(select all that apply) direct
2. ●case discussion
3. ●review of transition of care letter
4. ●other

Medical Expert

• □ME 2.2 Assess the patient’s health literacy and developmental readiness for the demands of the adult care setting
• □ME 2.2 Assess psychosocial issues that may affect health and/or access to services
• □ME 2.2 Assess adherence to treatment and monitoring plans
• □ME 2.4 Determine the setting of care appropriate for the patient’s health needs
• □ME 2.4 Anticipate, prevent and manage changes in health status at the time of transition
• □ME 2.4 Establish a plan for ongoing care in the local setting and/or for care prior to and during transfer
• □ME 4.1 Establish plans for ongoing care that include monitoring health status and managing adherence
• □ME 4.1 Assess the need, timing, risk and benefits of referring a patient to another health professional and/or care setting

Communicator

• □COM 4.3 Use communication skills and strategies that help the patient make informed decisions

Collaborator

• □COL 1.2 Consult as needed with other health care professionals, including other physicians
• □COL 3.1 Organize the handover of care to the most appropriate physician
• □COL 3.2 Summarize the patient’s issues including plans to deal with ongoing concerns
• □COL 3.2 Recognize and act on patient safety issues in the transfer of care
• □COL 1.1 Establish and maintain positive relationships with colleagues and other health care professionals

Leader

• □L 2.1 Apply knowledge of health care resources available in other care settings

Health Advocate

• □HA 1.2 Work with the patient to increase their understanding of their illness, health care needs, and opportunities for self-care
• □HA 1.1 Facilitate timely patient access to services and resources

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Observer role

1. ●rheumatologist
2. ●other physician
3. ●other health care professional

Medical Expert

• □ME 1.1 Demonstrate responsibility and accountability for decisions regarding patient care, acting in the role of most responsible physician
• □ME 2.4 Integrate recommendations from other health care professionals into management plans

Communicator

• □COM 1.3 Recognize when the values, biases, or perspectives of patients, physicians, or other health care professionals may have an impact on the quality of care and modify the approach to the patient accordingly

Collaborator

• □COL 1.2 Make effective use of the scope and expertise of other health care professionals
• □COL 1.1 Respond appropriately to input from other health care professionals
• □COL 1.1 Establish and maintain healthy relationships with physicians and other colleagues in the health care professions to support relationship-centred collaborative care
• □COL 1.3 Communicate effectively with physicians and other health care professionals
• □COL 1.3 Engage in respectful shared decision-making with physicians and other colleagues in the health care professions
• □COL 2.2 Implement strategies to promote understanding, manage differences, and resolve conflicts in a manner that supports a collaborative culture

Leader

• □L 3.1 Demonstrate leadership skills to enhance health care
• □L 4.2 Demonstrate efficiency and effectiveness in leading the interprofessional team

Scholar

• □S 2.1 Use strategies for deliberate, positive role-modelling

Professional

• □P 1.1 Intervene when behaviours toward colleagues and/or learners undermine a respectful environment
• □P 1.1 Exhibit appropriate professional behaviours

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Request type

1. ●biologics
2. ●insurance
3. ●homecare
4. ●disability
5. ●government supplements
6. ●other

Communicator

• □COM 5.1 Complete third party clinical documentation in a thorough, responsible and timely manner

Collaborator

• □COL 1.2 Negotiate overlapping and shared responsibilities with physicians and other colleagues in the health care professions in episodic and ongoing care

Leader

• □L 2.1 Allocate health care resources balancing optimal patient care and resource stewardship
• □L 2.2 Apply evidence and management processes to achieve cost-appropriate care

Health Advocate

• □HA 1.1 Facilitate timely patient access to services and resources
• □HA 1.1 Apply the criteria for reimbursement of pharmacologic and non- pharmacologic benefits

Professional

• □P 2.1 Fulfil clinical administrative responsibilities
• □P 1.1 Demonstrate honesty and integrity in all aspects of clinical work

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Case complexity

1. ●medium
2. ●high

Setting

1. ●longitudinal clinic (continuity of care)
2. ●transitional clinic (from pediatrics to adult care)
3. ●leave of absence
4. ●patient moving jurisdiction
5. ●consult service

Medical Expert

• □ME 4.1 Assess the need, timing, risk and benefits of referring a patient to another health professional and/or care setting

Collaborator

• □COL 3.1 Facilitate the handover of care to the most appropriate physician
• □COL 3.2 Summarize the patient’s issues including plans to deal with ongoing concerns as well as anticipated changes in the clinical course

Leader

• □L 2.1 Apply knowledge of health care resources available in other care settings

Health Advocate

• □HA 1.1 Work with patients to facilitate access to needed health services or resources

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Activity

1. ●research
2. ●quality improvement
3. ●educational project

Components completed

1. ●[select all that apply] identification of a question for investigation
2. ●literature review
3. ●protocol development
4. ●grant application
5. ●development of research ethics proposal
6. ●data gathering
7. ●data analysis
8. ●reflective critique
9. ●and dissemination

Format of dissemination

1. ●presentation
2. ●abstract
3. ●report
4. ●manuscript
5. ●publication

Leader

• □L 4.1 Organize work to manage clinical, scholarly and other responsibilities

Scholar

• □S 4.4 Identify, consult and collaborate with content experts and others in the conduct of scholarly work
• □S 4.4 Articulate focused questions for scholarly investigation
• □S 3.3 Critically evaluate the integrity, reliability, and applicability of health- related research and literature
• □S 4.5 Summarize the findings of a literature review
• □S 4.4 Select appropriate methods of addressing a given scholarly question
• □S 4.2 Identify ethical principles in research
• □S 4.4 Collect data for a scholarly project
• □S 4.4 Perform data analysis
• □S 4.5 Summarize and communicate the findings of a scholarly project

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Leader

• □L 4.2 Adjust educational experiences to gain competencies necessary for future practice

Scholar

• □S 1.2 Identify a specific area for improvement related to the needs of the intended community and/or career goals
• □S 1.1 Create and implement a learning plan that includes a structured approach to monitor progress of learning, including identifying timelines and accountabilities
• □S 1.1 Develop clear outcomes to assess progress of learning

Professional

• □P 2.1 Demonstrate a commitment to maintaining and enhancing competence
• □P 2.1 Demonstrate accountability by recognizing and responding to societal expectations of the profession

Case description

Feedback provided

Next steps