Background/Purpose: Rheumatology fellows are required to learn joint and periarticular procedures during their training but achieving the necessary expertise can be challenging if the rotations lack dedicated skills teaching. There is paucity of literature reporting how procedural proficiency evolves, and how the type and number of injections affect performance. 

To address these questions, we started an exclusive fellows monthly injection clinic and assessed the learners’ progress by analyzing their proficiency scores over time, comparing these between size of joints and number of procedures performed. We selected 10 or more injections as the number needed to achieve higher expertise. We then determined patient response  and side effects as secondary outcomes.

Methods: The monthly clinic was led by a single attending rheumatologist who demonstrated the proper technique prior to each encounter, supervised the procedure and provided instant feedback.  The proficiency score (PS) was given by the same teacher and used a numerical scale of 1-3 defined as 1-early, 2-progressing and 3-advanced.  Factors included in the PS are rapport, technique and documentation. We compared the PS between (1)initial and last fellow clinic, (2) procedure type classified as large joint/periarticular (knee/shoulder/hip) and small/medium joint/periarticular (hand/elbow/foot)  and (3) < 10 total procedures vs >10 done. Efficacy was measured by successful aspiration and/or significant pain relief . Patients were advised to call the clinic to report adverse effects or lack of response.

Results: Twenty five clinics took place between December 2020-June 2024 and covered 5 trainees so far. The fellows performed an average of 3.7 procedures/clinic for a total of 89. Proficiency scores (PS) were compared at initial (n=28) and last clinic (n=23) and between large (n=59) and small/medium joint/periarticular injections (n=30). Scores increased over time with higher expertise noted by last clinic compared to initial clinic [median 2.5 (IQR 2.3-3) vs 2(1-2.2), p = 0.0002]. Fellows achieved higher PS for large joint/periarticular procedures compared to the technically more difficult small/medium [2.3(2-2.5) vs 2(1-2.5), p=0.034]. PS was also higher when >10 procedures overall have been performed compared to < 10 injections [2.5(2-2.83) vs 2(2-2.3), p=0.0004]. The procedures were highly efficacious with a success rate of 95.5% (85/89) with no reported side effects.

Conclusion: This dedicated procedural clinic demonstrated factors that can improve proficiency among fellows. Our study proposes that a  minimum of 10 injections, long-term supervised training and increasing exposure to small joint injections are needed to achieve competency.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/long-term-proficiency-and-clinical-outcomes-of-a-novel-fellows-injection-clinic/