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College of
Health Sciences

Program overview

Quality Improvement Track
 Osteoporosis Track
 Musculoskeletal Ultrasound Track
 Medical Education Track
 Publications


Program overview

Your Rheumatology Fellowship will be defined by a curriculum that provides you with broad first-year experience and a focused second year based on interests you develop with your faculty mentors.

During your first year, you’ll hone all the fundamental skills you’ll need to practice clinical rheumatology, with rotations in the inpatient and outpatient settings.

Didactics take place most mornings before the start of clinic. These can include lectures by rheumatology faculty, rheumatology board review, journal club and interdepartmental complex case conferences delivered by rheumatology fellows and trainees in other specialties (neurology, pulmonology, dermatology, nephrology).

Over the course of your two years, you’re also required to complete one research and one quality improvement project per ACGME guidelines. Dedicated months are set aside so you can pursue these projects.

The curriculum schedule is:

  • Three months of research
  • Three months of inpatient consults
  • Four months of outpatient rheumatology
  • One month of osteoporosis
  • One month of sports medicine

All first-year fellows participate in musculoskeletal ultrasound clinics, quality improvement curriculum and the education of residents and medical students.

These experiences will help guide you as you determine your second-year track or tracks, choosing from:

  • Musculoskeletal ultrasound
  • Quality improvement
  • Medical education
  • Osteoporosis

All second-year fellows complete these required rotations:

  • Three months of research
  • Three months of inpatient consults
  • Two months of outpatient rheumatology

The rest of your time is dedicated to your specific track or tracks and to electives.


Quality Improvement Curriculum and Specialty Track

Introduction

  • The QI principles in our Rheumatology Fellowship curriculum are modeled after the Institute for Healthcare Improvement’s (IHI) Model for Improvement.

Goals

  • Meet ACGME requirements
  • Introduce trainees to key concepts of quality improvement and provide opportunities to further expand knowledge for those with deeper interest in quality work
  • Learn a systematic approach to performing a QI project
  • Practice a shared culture of Improvement in our patients’ care and safety as well as collaboration and teamwork within our department and healthcare system

Each first-year fellow can choose the standard or QI track.

Table 1. Quality Improvement for Rheumatology Fellows: Standard vs QI Track

Rheumatology Fellow QI  Standard   QI Track
 3 Didactic lectures   X  
 6 Didactic lectures   X
 Independent Online Learning (IHI)   X
 Certificate in Quality & Safety   X 
 QI Project X X
 Length of Project ~12 months  X   
 Length of Project ≥ 12 months    X
 6 months QI/Research blocked time over 2 years   X  
 7 months QI/Research blocked time over 2 years    X
 Attend 1 National QI Conference (funded)    X
 ACR Abstract Submission (June of each year)   X  X
 Publication (if publishable material) X   X

 

Standard QI for rheumatology fellow

Goal: Meet ACGME requirements

First year
1. 3 didactic sessions
2. Small QI project (timeframe ~ 12 months) and meet monthly
3. 3 months of QI/research per year
4. Submit abstract to ACR every June

Second year
5. Continue to meet every other month to discuss project and work on possible publication
6. Publication by February of the second year of fellowship prior to graduation (if publishable material)

QI track for rheumatology fellow

Goal: Meet ACGME Requirements and pursue QI interest

First year
1. Six didactic sessions
2. Thirteen independent online didactics (IHI website) – earn QI certificate in Quality & Safety
3. Longer or more complex QI project (timeframe ≥12 months) and meet monthly
4. Seven months of QI/research over the two-year period
5. Funding to attend a QI conference
6. Submit abstract to ACR every June

Second year
7. Continue to meet every other month to discuss project and work on possible publication
8. Publication by February of the second year of fellowship prior to graduation (if publishable material)

Jonida Cote, DO
Assistant Director of Quality Improvement
Department of Rheumatology
jkcote@geisinger.edu


Osteoporosis Curriculum and Specialty Track

Working under the premise that rheumatologists can be “best owners” of this clinical domain, the curriculum encompasses clinical care of post-menopausal osteoporosis, male osteoporosis, GIOP and secondary causes of osteoporosis and occasionally, osteoporosis in patients less than 50.

We’re committed to secondary fracture prevention, and our FLS program is called HiROC. You’ll be consulted in hospital for patients over age 50 who have fractures. After evaluation and discharge, these patients will be transitioned to care in outpatient HiROC. You’ll be a key team member and exposed to system-based, clinical DXA interpretation, a skill you’ll learn with ISCD-certified clinical densitometrists.

You’ll be exposed to all the key osteoporosis clinical fracture trials and all FDA-approved medications used in clinical care. Over your two years, we hope that you’ll strive to become an “FLS champion” and apply your skills in your ultimate practice Finally, you’ll be eligible to take the ISCD certification exam and continue to be a “bonehead” by embracing most facets of osteoporosis and osteoporosis care.

Goals:

  1.  To respect the significant clinical problem of osteoporosis, its epidemiology and its significant morbidity and mortality
  2.  To glean a better understanding of the process of bone remodeling and to appreciate the components of bone strength and quality
  3.  To review the fundamentals of bone densitometry, its interpretation and integration within system-based care with interpretation into a system-wide electronic medical record
  4.  To realize the importance of vertebral fracture identification and application of point of service testing with VFA/mobile DXA
  5.  To grasp the design of clinical osteoporosis fracture trials and to read the major clinical fracture trials with the FDA-approved osteoporosis therapies and to apply that knowledge into clinical care
  6.  To participate in outpatient HiROC
  7.  To participate in inpatient HiROC, become an FLS champion
  8.  To register, take and pass the ISCD bone densitometry certification examination
  9.  To become an osteoporosis leader and champion in one’s practice post-fellowship and never let this spirit waver, tire or extinguish

Thomas P. Olenginski, MD
Director, HiROC and Osteoporosis Track
Department of Rheumatology
tpolenginski@geisinger.edu


Musculoskeletal Ultrasound Curriculum and Specialty Track

Description of rotation

Musculoskeletal ultrasound (MSUS) allows for real-time, dynamic diagnostic and management decisions at the point of care in rheumatology clinic. You’ll have the opportunity to tailor your learning to include a musculoskeletal ultrasound track in the second year, if you choose.

MSUS rotations allow you to learn the technical skills necessary to perform diagnostic ultrasounds of the following required joints: hand, wrist, elbow, shoulder, hip, knee, ankle and foot. You’ll need to master the appropriate ultrasound anatomy corresponding to each examination and recognize normal anatomy and the pathologies that can occur in rheumatology patients.

Your guided curriculum will be based on guidelines from the Ultrasound School of North American Rheumatologists (USSONAR) program and Rheumatology Musculoskeletal Ultrasound (RhMSUS) certification from the American College of Rheumatology (ACR). The ultimate goal is to prepare you to sit for RhMSUS certification.

During your first year, you’ll participate in regularly scheduled ultrasound clinics and academic sessions with the goal of becoming comfortable with using the ultrasound machine to obtain studies of the required joints for rheumatology. You should make a concerted effort to learn the ultrasound anatomy and be able to recognize basic structures on ultrasound imaging while learning the basics of the ultrasound machine, both transducers and image settings.

You’ll learn ultrasound from USSONAR- and RhMSUS-certified trainers in the central, west and northeast regions and will be expected to train with all providers at various locations.

Skills for ultrasound

  • Learning how to use the equipment
    • Basic ultrasound physics
    • Knobology
    • Becoming familiar with the US machine
    • Understanding Doppler physics
    • Maintenance of the US machine
  • Performing US following USSONAR and Backhaus scanning guides based on EULAR 2017 guidelines for US scanning
    • This will be done with specific attention to understanding of sonographic anatomy of each joint
      • Shoulder
      • Elbow
      • Wrist
      • Hand
      • Hip
      • Knee
      • Ankle
      • Foot
  • Recognizing pathology and indications of ultrasound for various clinical scenarios based on OMERACT definitions for pathology
    • Rheumatologic
      • Crystalline arthropathies
      • Rheumatoid arthritis
      • Osteoarthritis
      • Ankylosing spondylitis
      • Inflammatory tendon pathology
      • Bursitis
      • Baker’s cyst
      • Learning how to monitor disease activity based on Doppler
    • Mechanical
      • Tendinopathy
      • Enthesopathy
    • Neuropathic
      • Nerve entrapment, i.e., carpal tunnel
    • Procedural
      • CTS and trigger finger injections
      • Small joint aspiration and injection
      • Intermediate joint aspiration and injection
      • Large joint aspiration and injection

  • Implementing MSUS into best practice
    • AIUM compliance
    • ACR guidelines for reasonable use of MSUS
    • MSUS required readings

  • RhMSUS requirements of fellows (adapted from RhMSUS Candidate Handbook)
    • Fellows will keep a log of their personal scans performed
    • Two pathways to qualification for board examination (Shall be required of fellows who choose to participate in the MSUS track).
      • Path one: Collect 150 US studies on separate days and acquire 24 CME credits pertaining to MSUS with 14 credits of live CME
      • Path two: Collect 150 US studies on separate days and complete the USSONAR certification

Academic schedule

  • Twelve-month rolling didactic schedule will be held the second Wednesday of the month
    • July: Introduction to US
    • August: MSUS of the hand
    • September: MSUS of the wrist
    • November: MSUS of the elbow
    • December: MSUS of the shoulder
    • January: MSUS of the hip
    • February: MSUS of the knee
    • March: MSUS of the ankle
    • April: MSUS of the foot
    • May: Introduction to US guided injections
    • June: MSUS pathology review

  • Each monthly session will be broken into an hour long didactic followed by hands-on scanning sessions in which you’ll focus on the joint of the day.

MSUS track for second-year fellows
If you choose the MSUS track, you’ll have several rotations specifically designed to perform and learn ultrasound. Rotations will be two and four weeks long and held in Danville, Wilkes-Barre and State College. You’ll attend specific US clinics in Danville and Wilkes-Barre. You’ll continue to refine your skills with the US machine and learn to recognize pathology on ultrasound of the required joints. You should also be able to produce ultrasound reports documenting your findings. You’ll learn skills to perform ultrasound-guided injections on required joints for pathologies where indicated. You’ll expand evidence-based knowledge for reasonable use of ultrasound in rheumatology as dictated by the ACR guidelines for reasonable use of MSUS. And you’ll apply to participate, if accepted, in the USSONAR MSUS course to improve your skills.

Academic schedule

  • August/September: Two-week rotation to become more proficient in US and image acquisition.
  • October: USSONAR application and trial period. You’ll have a full month dedicated to ultrasound to prepare your portfolios for USSONAR and prepare for the acceptance exam at the end of the month.
  • December: Two-week rotation to continue to hone skills and start acquiring the required pathologies for USSONAR prior to the course.
  • January/February: Attend USSONAR live/virtual course
  • March through May: Attend NYU course for Intermediate US if not accepted into the USSONAR program. You’ll have at least two weeks to hone skills further in preparation for USSONAR final exam scheduled for May.
  • June: If able, sit for RhMSUS board certification if meeting the requirements for application. Otherwise, having met the requirements to sit for certification after completion of fellowship.

Goals

  • Development of technical skills with the ultrasound machine to be able to obtain studies of the required joints to diagnose pathology in rheumatologic conditions
  • Develop a mastery of the ultrasound anatomy as it pertains to musculoskeletal ultrasound for rheumatology
  • Perform ultrasound-guided injections where indicated for patients who need intervention
  • Develop skills interpreting results of ultrasound studies to produce ultrasound reports based on findings
  • Ultimately, participate in the USSONAR course and prepare to sit for RhMSUS boards

David H. Bulbin, DO
Program Director, Director of Ultrasound Track
Department of Rheumatology
dhbulbin@geisinger.edu


Medical Education Track

Fellows who are interested in pursuing a career as a clinician educator may choose to pursue the medical education track. Along with the day-to-day clinical teaching that all fellows do with residents and medical students, you’ll have the opportunity to receive additional training in foundational education topics through the Geisinger Education Institute, including principles of small group learning, giving effective feedback and presentation design. Fellows who pursue this track also complete a scholarly medical education project with faculty guidance.


Publications

These pubs are not just part of the "Medical Education Track".
The following list is not exhaustive.

2021

2020

  • Bielawski, M., Newman, E.D., & Schroeder, L.L. Use of a novel electronic auto-notification process to manage transitions of care in rheumatic patients on DMARD therapy. Accepted at the Geisinger Scholarship Days 2020, Danville, PA
  • Brunner E, Ting T, Vega-Fernandez P. Musculoskeletal ultrasound in children: Current state and future directions. Eur J Rheumatol. 2020;7(Suppl 1):S28-S37. doi:10.5152/eurjrheum.2019.19170
  • Bulbin, David, et al. "Implementation of a Musculoskeletal Ultrasound (MSUS) Curriculum in an Academic Rheumatology Fellowship Within an Integrated Health System: A Four-Year Experience." ARTHRITIS & RHEUMATOLOGY. Vol. 72. 111 RIVER ST, HOBOKEN 07030-5774, NJ USA: WILEY, 2020.
  • Conley RB, Adib G, Adler RA, et al. Secondary Fracture Prevention: Consensus Clinical Recommendations from a Multistakeholder Coalition. 2020. JBMR 2019 DOI:10.1002/jbmr3877 Note: Olenginski, TP is author 40 in this publication     
  • Rottmann E., Cote J., Grassi D., Thomas S., Chronowski J., Schroeder L.L., Pugliese D., Newman E.D. Pharmacist Use of Protocol Driven Medication Refills and its Impact on Rheumatologists Satisfaction and Burnout. Oral presentation at 2020 American College of Rheumatology Annual Meeting (Virtual).
  • Rottmann, E., Bankert, J., Berger, A., Kirchner, L., Dewalle, J., Meissner, M., George, J., Bucaloiu, I.D., Sugunaraj, J.P., Penupolu, S. and Bulbin, D., "Epidemiology and Geographic Evaluation of ANCA-associated Vasculitis (AAV) at a Rural Academic Health Center Utilizing an Electronic Health Record (EHR)." ARTHRITIS & RHEUMATOLOGY. Vol. 72. 111 RIVER ST, HOBOKEN 07030-5774, NJ USA: WILEY, 2020
  • Schroeder, L.L., Swinden, J. Longitudinal Diagnostic Error Reduction Curriculum for Internal Medicine Residents. Accepted at the Geisinger Scholarship Days 2020, Danville, PA.
  • Vega-Fernandez P, De Ranieri D, Oberle E, Bukulmez H, Lin C, Shenoi S, Thatayatikom A, Woolnough L, Corbin K, Benham H, Brunner E, Henrickson M, Ballenger L, Haro S, Schutt C, Proulx-Gauthier J, Janow G, Altaye M, Cassedy A, Roth J, Ting T. Novel Ultrasound Image Acquisition Protocol and Scoring System for the Pediatric Ankle [abstract]. Arthritis Rheumatol. 2020; 72 (suppl 10). https://acrabstracts.org/abstract/novel-ultrasound-image-acquisition-protocol-and-scoring-system-for-the-pediatric-ankle/.
  • Wriston, D. J., Norfolk, E. R., Smith, L. M., Chen, G., & Bulbin, D. H. (2020). Doxycycline-Induced Antinuclear Antibody and Antineutrophil Cytoplasmic Antibody Associated Vasculitis: A Case Report and Literature Review. Case Reports in Rheumatology, 2020.

2010s

  • Bansal R, Bulbin D, Denio A, Kelsey S, Harrison H. Clinical Relevance of a “False Negative” Enzyme Linked Immunoassay: Which Antinuclear Antibody Test is Preferred by Rheumatologists in an Integrated Health System? Arthritis Rheum. 2012; 64:S613doi: 10.1002/art. 37735
  • Bielawski, M., Newman, E.D., & Schroeder, L.L. Use of a novel electronic auto-notification process to manage transitions of care in rheumatic patients on DMARD therapy. Oral presentation at the 2019 American College of Rheumatology Annual Meeting, Atlanta, GA.
  • Brunner E, Cote J, Bansal R, Ansar M, Harrington T.Thrombotic Vasculopathy in a patient with initially undetected breast cancer. Case series. J of clinical rheumatology. Volume 20, Nov 2014
  • Brunner E, Tasan L, Torok KS, Rockette-Wagner B, Zigler CK, Schollaert-Fitch K, Koontz D, Oddis CV, Aggarwal R. Stepping It up: The Use of Physical Activity Monitors As an Outcome Measure in Juvenile Myositis [abstract]. Arthritis Rheumatol. 2018; 70 (suppl 10). https://acrabstracts.org/abstract/stepping-it-up-the-use-of-physical-activity-monitors-as-an-outcome-measure-in-juvenile-myositis/
  • Bulbin D, Denio AE, Berger A, Brown J, Maynard C, Sharma T, Kirchner HL, Ayoub WT. Improved Gout Outcomes in Primary Care Using a Novel Disease Management Program: A Pilot Study. Arthritis Care & Research. 2018 Feb 13.
  • Bulbin D, Meadows A, Denio A, Kirchner L, Kelsey S, Harrison H. Do Rheumatologists (and Other Specialists) Practice What We Preach? A Study of Serology Ordering Patterns with Attention to Subserologies when the Antinuclear Antibody By Enzyme Linked Immunosorbent Assay is Negative, and the Clinical Significance of these Positive Subserology Results. 2013 Annual Meeting Abstract Supplement. Arthritis & Rheumatism, 65: S361. doi: 10.1002/art.38216
  • Bulbin D, Meadows A, Kelsey S, Harrison H, Denio A. Choosing Subserologies Wisely: an Opportunity for Rheumatologic Healthcare Resource Savings. (2014), 2014 ACR/ARHP Annual Meeting Abstract Supplement. Arthritis & Rheumatology, 66: S1–S1402. doi: 10.1002/art.38914
  • Bulbin, D, Bowen T, Wu H, and Harrington T. Pacinian Neuroma: an Uncommon and Unique Cause of Digital Pain. Poster Session presented at: 2013 ACOI Annual Convention and Scientific Sessions; 2013 Oct. 6-11; Indian Wells, CA
  • Bulbin, D, Schroeder L, Denio A, Schuerch C. The Nosebleed that Got Away: An Unusual Diagnosis of Granulomatosis with Polyangiitis (GPA). Poster Session presented at: 2014 Pennsylvania Rheumatology Society Annual Meeting; 2014 Sep 19-21; Hershey, PA
  • Bulbin, D., Maynard, C., Sharma, T., Denio, A. E., Brown, J., Berger, A., ... & Ayoub, W. T. (2015). Improving Gout Outcomes Using a Disease Management Program within an Integrated Health System. Arthritis & Rheumatology, 67, 1341-1343.
  • Bulbin, D., Meadows, A., Kelsey, S., Berger, A., Kirchner, L. H., Harrison, H., & Denio, A. E. (2015). Choosing Subserologies More Wisely: Implementing Anti-nuclear Antibody (ana) Reflex Testing and Education to Reduce Unnecessary Costs in an Integrated Healthcare System. Arthritis & Rheumatology, 67, 3005-3006.
  • Cote J, Berger A, Kirchner L, Bili A.Low Vitamin D level is not associated with increased incidence of Rheumatoid Arthritis. Rheumatology Int. April 2014.
  • Cote J, Bili, A.Patterns of Aspirin use in Rheumatoid Arthritis.ISRN Rheumatology Oct 2013.
  • Cote J, Meadows A, Bili A, Harrington T.TNF-α inhibitor induced Sarcoidosis, case series.TheRheumatologist Nov 2013
  • Dunn, PJ, Webb D, Olenginski TP. Geisinger High-Risk Osteoporosis Clinic (HiROC): 2013-2015 FLS Performance Analysis. Osteoporos Int. (2018) 29:451-457.
  • Halupa, A. J., Strony, R. J., Bulbin, D. H., & Kraus, C. K. (2019). Pseudogout Diagnosed By Point-of-care Ultrasound. Clinical practice and cases in emergency medicine, 3(4), 425.
  • Olenginski, TP (2018). Fracture Liaison Service: US Perspective, Seibel MJ and Mitchell PJ, Editors, Secondary Fracture Prevention, An International Perspective (pp155-172), New York, NY: Elsevier, Inc.
  • Rothman MS, Olenginski TP, Stanciu I, Krohn K, Lewiecki EM. Lessons learned with BoneHealth TeleECHO: making treatment decisions when guidelines conflict. Osteoporos Int (2019) 30:2401-2406 , https://doi.org/10.1007/s00198-019-05147-8
  • Sanders, L. Patient story collaboration Cote J.Was a patient’s arthritis medicine making her sick? New York Times. March 2015
  • Sharma T, Wasko, C. M, Tang X, Vedamurthy D, Yan X, Cote J, Bili A.Hydroxychloroquine Use Is Associated with Decreased Incident Cardiovascular Events in Rheumatoid Arthritis Patients. J Am Heart Assoc. 2016;5: e002867 doi:10.1161/JAHA.115.002867
  • Tasan L, Brunner E, Squires J, Aggarwal R, Oddis CV, Zigler CK, Schollaert-Fitch K, Mirizio E, Torok KS. Analyze Myositis with Ultrasound and Exercise (AMUSE) Kids- Initial Analysis of Longitudinal Data [abstract]. Arthritis Rheumatol. 2018; 70 (suppl 10). https://acrabstracts.org/abstract/analyze-myositis-with-ultrasound-and-exercise-amuse-kids-initial-analysis-of-longitudinal-data/
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