Background/Purpose

In 2012, the Accreditation Council for Graduate Medical Education (ACGME) announced the required implementation of standardized milestones with entrustable professional activities (EPAs) for the semi-annual evaluation of resident/fellow performance which must be implemented by November 2014. However, little guidance was rendered as to the incorporation of these milestones and EPAs into the curriculum of a subspecialty training program. Our rheumatology fellowship has had a formal musculoskeletal (MSK) radiology rotation for the past five years as part of its core curriculum and has integrated  internal medicine subspecialty curricular milestones with MSK radiology specific EPAs into this curriculum.

Methods

Utilizing a modified Delphi technique via e-mail, faculty and current fellows from the program established a consensus on EPAs for MSK radiology. The EPAs were individually rated using a nine-point Likert scale, with 1 being disagreement with the EPA and 9 being the most agreement. Agreed upon EPAs were then used as a foundation for the development of curricular milestones. These milestones were designed using a 5-level Dreyfus model which were defined as novice/critical deficiency, advance beginner, competent, proficient/ready for unsupervised practice, and expert/aspirational. The milestones were then incorporated into the core curriculum, with an emphasis placed on the “proficient” level and above for teaching purposes.

Results

Six faculty members and 2 rheumatology fellows participated in the process. Six EPAs were initially developed, and after two rounds of comments with rewording and scoring, all six EPAs rated in the highest agreement scores (see table). Curricular milestones for MSK radiology were then established in keeping with these EPAs. These curricular milestones were integrated into our core MSK radiology lecture series.

Entrustable Professional Activities (EPAs)	Mean Likert Score
1. Order and utilize appropriate diagnostic imaging studies for evaluation and management of patients with rheumatic disease.	8.9
2. Identify the optimal imaging modalities for patients with rheumatic disease within the context of patient comorbidities, preferences, treatment goals, financial considerations and insurance requirements.	8.3
3. Interpret signs of acute and/or chronic musculoskeletal disease on radiography and know when to consult a radiologist for further evaluation and interpretation.	7.7
4. Understand the written interpretation reports of radiography, computed tomography, ultrasound, magnetic resonance imaging, scintigraphy and bone mineral density studies and utilize the results to optimize the care of the patient with rheumatic disease.	8.6
5. Communicate directly with consulting radiologists when necessary to determine the optimal diagnostic studies to evaluate and manage patients with rheumatic disease.	8.1
6. Effectively communicate with patients their diagnostic imaging options, indications, alternatives and results in a clear and easily understood manner.	8.6

Conclusion

The interpretation and application of MSK radiology is critical in the training of a rheumatology fellow. Incorporating a dedicated radiology rotation which addresses specific milestones and EPAs is one way of ensuring trainees are exposed to a quality, uniform curriculum that meets the ACGME’s next accreditation system requirements.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/rheumatology-specific-milestones-for-a-musculoskeletal-radiology-curriculum/