As required by the ACGME, the duration of our program is two years, and all fellows are Board-eligible after this time. However, seeing an academic project through to completion will often take longer, and we offer fellows the opportunity to stay for an additional year in a junior faculty position, as well as to consider making their career here with us.
First Year Vs. Second Year
The first year of fellowship is entirely devoted to intensive patient care and educational experiences. In the second year, in addition to ongoing clinical training, fellows choose to focus their activities in one of four tracks - research, advanced clinical training, education, or quality improvement (and sometimes a hybrid of these activities). These all occur with close faculty mentorship and oversight.
Institutions & Populations Served
Our 1,005-bed University Hospital and the majority of clinics are within the main Medical Center campus, however, fellows can also participate in near-by satellite clinics. Our clinical programs serve as the Rheumatology referral center for all of Michigan Medicine’s network of primary care and other sub-specialty clinics, as well as being the tertiary referral center for our entire region with approximately 16 million residents. The combination of local and regional referrals ensures that our Fellows care for patients covering the entire spectrum of rheumatologic diseases, from prevalent to rare and complex.
Our service to the Ann Arbor VA Hospital, proximity to the demographically diverse patient population of south-eastern Michigan that includes areas and populations designated by the Health Resources and Services Administration as medically underserved, and commitment to provide care to large numbers of patients whose medical care is supported by Medicaid and a county low-income health care plan, ensures our fellows encounter a broad and diverse patient population.
Ambulatory Clinic Assignments
In the 2019-2020 fiscal year, we anticipate that Michigan Medicine Rheumatology Clinics will evaluate 29,000 outpatients and an additional 3,500 patients at the VA Ann Arbor Hospital.
All Fellows have their own half-day continuity clinics, managing patients longitudinally with ongoing supervision from the same faculty mentor. Fellows are assigned two continuity clinics each week in their first year and one to two in the second year depending on their training track.
All Fellows also rotate through our weekly VA clinic and through specialty clinics - Scleroderma, Procedures, Urgent-New-Patient, and Pediatric Rheumatology.
Typically, first year Fellows have 15 half-day clinics per month and second year Fellows have 5-12 half-day clinics per month depending on their training track. Standard schedules include evaluation of two new patients and four return visits. In the first year, each Fellow evaluates approximately 300 new patients and sees approximately 600 return visits.
Inpatient Consult Service
We provide inpatient consults for the University Hospital and the Ann Arbor VA Hospital. This is a very busy service with a daily census of approximately 15 patients, and we typically evaluate approximately 4 new consults per day. Two Fellows are always assigned to this service with one attending (usual rotation: 2 weeks on, 1-3 weeks off), and they supervise 2-4 medical residents and students. In their first (clinical) year, each Fellow evaluates approximately 600 new in-patient consultations and approximately 2,000 ongoing follow-ups consults.
Transitioning from First to Second Year
The program director works closely with each fellow to choose second year activities that best fits their long-term career goals. Fellows can choose from one of the these tracks or a hybrid.
Fellows initiate a mentored research project with close supervision from a qualified faculty member. A key element is the mentoring process with a year-long close interaction between Fellows and their individual faculty mentors. Many faculty mentors oversee large research programs and Fellows benefit from participation in work-in-progress seminars, discussion groups, and collaborations. While most fellows choose a mentor from within rheumatology, they are not restricted to our faculty. We have relationships with many different groups within our institution and Fellows have considerable freedom in choosing a project and mentor.
Advanced Clinical Track
Fellows maintain the same clinic assignments that they had in their first year, are assigned to the inpatient consult service for 4-6 weeks, are offered the opportunity to become certified in musculoskeletal ultrasound through either the USSONAR or ACR-MSUS courses, and complete rotations in sub-specialty clinics of interest to them. These have included sports medicine, metabolic bone disease, neuromuscular, and physical medicine. Fellows may also spend time with musculoskeletal radiology and the immunopathology lab.
Quality Improvement Track
The Quality Improvement Track is new and was introduced in July 2020. The curriculum includes certification through the Institute for Healthcare Improvement Open School, participation in the University of Michigan Patient Safety and Quality Leadership Scholars Program (PASQUAL), a half-day per week course over five months, which provides training in principles, methods, and scholarship related to quality and patient safety, and a specific QI project.
Fellows maintain the same clinic assignments that they had in their first year, are assigned to the inpatient consult service for 4-6 weeks, and participate in the Medical Education Scholars Program, a half-day per week course over ten months, which focuses on training in educational leadership, teaching, and scholarship.
An oversight committee has been implemented for second year fellows. Committee members are the program director, division chief, and faculty with expertise in:
- Basic Science - J. Michelle Kahlenberg, MD, PhD
- Clinical Research - Dinesh Khanna, MD, MSc
- Quality Improvement - Puja Khanna, MD, MPH
- Medical Education - Seetha Monrad, MD (Assistant Dean for Medical Education)
The committee meets before the beginning of the second year and then every three months. Fellows submit proposals that articulate their goals and objectives, and provide progress reports at subsequent meetings. Fellows are expected to submit abstracts, manuscripts, and teaching modules, as appropriate. Fellows present a formal seminar to the entire Division towards the end of the year, highlighting activities and accomplishments.
Fellows As Educators
An integral element of training of all Fellows is developing skills as educators at the bedside and in more formal settings. Fellows have many opportunities to supervise students and residents in clinic and on the wards. They also prepare formal presentations for Grand Rounds conferences (conference details are included under the Didactic Program section). Additionally, we support an annual award to recognize a first year fellow who has shown exceptional teaching talent. There is also an option for specialized second year clinician-educator track training.
Fellows attend the following sessions:
- Core Curriculum. Weekly. Basic science and clinical topics are presented by faculty.
- Program Director Practicum. Weekly. Discussion of current cases, practical clinical topics, board review.
- Second Year Fellows Board Review. Second weekly meeting with Dr. David Fox to discuss assigned topics.
- Grand Rounds. Weekly. Presentations by Fellows, faculty, visitors.
- Case Discussion. Monthly. Faculty and Fellows discuss challenging cases.
- Journal Club. Monthly. Fellows critically evaluate recent publications.
- Research Seminars. Monthly. Attended by faculty, Fellows, graduate students, post-doc’s.
- Pathology-Rheumatology Conferences. Sixth weekly. Biopsy material is presented by Pathology faculty.
- Radiology-Rheumatology Conferences. Sixth weekly. Fellows practice interpretation, followed by teaching from Radiology faculty.
- Ultrasound. Sixth weekly. A USSONAR-trained faculty member teaches anatomy and ultrasound, with each Fellow actively participating.
- All Fellows acquire extensive experience in arthrocentesis and injection. Initial training includes didactic lectures, then Fellows rotate through procedures clinics in both years.
- Polarized light microscopy
- Examination of synovial fluid is performed using our own equipment. Training includes didactic lectures and demonstrations using archived material.
- Nailfold capillary microscopy
- We use a dissecting microscope in the Scleroderma clinic for high-resolution imaging, and all Fellows are given a Dermatoscope for portable use.
- Tissue biopsies
- Fellows observe needle muscle biopsy and minor salivary gland biopsy, and have the opportunity to become proficient in these procedures.
- All Fellows have training in musculoskeletal ultrasound in their first year, and are offered the opportunity for intensive training in the second year with the USSONAR course or ACR-MSUS training.