Assessing Pediatric Rheumatology Fellow Competence in the Milestone Era: Past, Present, and Future.

Starting in 2015, pediatric rheumatology fellowship training programs were required by the Accreditation Council for Graduate Medical Education to assess fellows' academic performance within 21 subcompetencies falling under six competency domains. Each subcompetency had four or five milestone levels describing developmental progression of knowledge and skill acquisition. Milestones were standardized across all pediatric subspecialties. As part of the Milestones 2.0 revision project, the Accreditation Council for Graduate Medical Education convened a workgroup in 2022 to write pediatric rheumatology-specific milestones. Using adult rheumatology's Milestones 2.0 as a starting point, the workgroup revised the patient care and medical knowledge subcompetencies and milestones to reflect requirements and nuances of pediatric rheumatology care. Milestones within four remaining competency domains (professionalism, interpersonal and communication skills, practice-based learning and improvement, and systems-based practice) were standardized across all pediatric subspecialties, and therefore not revised. The workgroup created a supplemental guide with explanations of the intent of each subcompetency, 25 in total, and examples for each milestone level. The new milestones are an important step forward for competency-based medical education in pediatric rheumatology. However, challenges remain. Milestone level assignment is meant to be informed by results of multiple assessment methods. The lack of pediatric rheumatology-specific assessment tools typically result in clinical competency committees determining trainee milestone levels without such collated results as the foundation of their assessments. Although further advances in pediatric rheumatology fellowship competency-based medical education are needed, Milestones 2.0 importantly establishes the first pediatric-specific rheumatology Milestones to assess fellow performance during training and help measure readiness for independent practice.

Assessing Barriers to Uveitis Screening in Patients with Juvenile Idiopathic Arthritis Through Semi-Structured Interviews.

INTRODUCTION: Uveitis is a significant complication in patients with juvenile idiopathic arthritis (JIA) and can be asymptomatic until vision loss develops. Published guidelines recommend uveitis screening eye examinations every 3-12 months depending on multiple factors, but no literature evaluates adherence with and barriers to obtaining these screening eye examinations. This study assesses barriers in nonadherent patients to establish key drivers for future interventions. METHODS: We identified patients with JIA who were nonadherent with uveitis screening guidelines through the electronic medical record (EMR). A rheumatologist conducted semistructured interviews with the patients or guardians regarding the patients' most recent eye examinations, knowledge of the screening frequency, and barriers to completing the eye examinations. The results were qualitatively analyzed to determine any categorical variables present. RESULTS: Ninety-two patients were identified as nonadherent, and the rheumatologist interviewed 45 patients or guardians. Categories identified following the interviews were system problems, access to care issues, and knowledge deficits. The largest category identified was system problems that included most recent eye examination not being in the EMR, the wrong eye provider identified in the EMR or difficulty with scheduling eye appointments. CONCLUSIONS: This qualitative study identified categories of barriers to obtaining screening eye examinations in patients with JIA. Identification of these barriers will facilitate the development of a specific aim and key driver diagram to guide future quality improvement interventions.