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A Framework of Competencesfor the

Special Interest Module in Paediatric

RheumatologyJan 2014

Royal College of Paediatrics and Child Healthwww.rcpch.ac.uk

A Framework of Competences for the Special Interest Module in Paediatric Rheumatology___________________________________________________________________________________

CONTENTS

Section 1Introduction 4

Section 2 General CompetencesKnowledge and understanding 6

Skills 6

Leadership and Management 7

Training and Research 7

Communication Skills in Paediatrics 8

Section 3 Practical Procedures and Investigations in Paediatric Rheumatology Pharmacology and Therapeutics 9

Appendix 1Guidance Checklist for Training 10

Appendix 2Assessment Guidance 13

(c) 2014 Royal College of Paediatrics and Child Health

Section 1 Introduction

Who is this book for?

Royal College of Paediatrics and Child Health 2014 2


It is for doctors at Level 3 in their General Paediatric training who wish to work

towards an expertise in Paediatric Rheumatology during Level 3 training or

post CCT. It is also there to guide tutors and educational supervisors.

Why do I need it?This book gives you and your tutors’ guidance about the competences you

need to cover in addition to the Framework of Competences for Level 3

Training in General Paediatrics. It gives you a clear picture of what you have

to achieve by the end of this module of training in order to have expertise in

this area.

How do I use the book?You can sit down with the book on your own and use it to help you identify

areas of practice that you need to work on and those areas in which you feel

fairly confident. You can talk to your tutor about the balance of your

experiences and look for ways to ensure you cover all areas you need to. It

should be used by Schools and Educational Supervisors to ensure that a

programme of training is developed in Level 3 which will allow the trainees to

achieve these competences. In determining this programme, liaison with the

relevant CSAC is important. In the appendix, there is guidance for training in

the module which the programme must adhere to.

ProgressionFollowing completion of Level 3 training and the module, the CCT holder

should be competent to take up a post as a General Paediatrician or a

General Paediatrician with a Special Expertise in this area. It is expected that

there will be a requirement in paediatric services for consultants with special

expertise provided by the module. Such posts will usually form part of a

Regional Specialty Network including working with accredited sub-specialties

in this area.

A note about the format of this documentThis framework sets out the additional competences which should be

achieved by the end of Level 3 training. The trainee also has to achieve all

the competences in the Level 3 General Paediatric Framework.



AssessmentThe RCPCH Assessment Strategy (GMC approved) for Level 3 Training will

be used. Trainees working with their educational supervisors should ensure

that the Assessment Strategy is tailored to cover the area of Special Expertise

as well as General Paediatrics and that learning and assessment are well

documented within the e-portfolio.

PilotThis special expertise module is being introduced as a pilot. The College will

be seeking feedback from the Trainees, Educational Supervisors, Schools of

Paediatrics, CSACs and potentially in future from Employ NHS Trusts and

Regional Networks. This will look at;

1. Need for training in this module

2. Addition or omission of competences unique to the module

3. Feasibility of delivering the module within Level 3 General Paediatric

training

4. Usefulness of the standards for training for the module.

5. Outcome of trainees undertaking the module

6. Need for revision of the competences

7. Need for further assessment



Section 2 General Competences in Paediatric Rheumatology Knowledge and UnderstandingBy the end of themodule in Paediatric Rheumatology, you will:

know about common mechanical and non-inflammatory causes of

joint, muscle and back pain in children and adolescents

know about potentially life threatening conditions that present with

musculoskeletal features such as inflammation, malignancy,

infection, vasculitis and macrophage activation syndrome

be aware of the differential diagnosis of rheumatic diseases

including congenital bone, inherited or metabolic conditions, their

musculoskeletal presentations and when to suspect them

understand the disease associations of rheumatological conditions,

in particular juvenile idiopathic arthritis and eye disease

be aware of guidelines for and demonstrate experience of

managing fever, infection, exposure to infectious diseases and

vaccination in the immunocompromised child

knowledge of immuno-suppressive therapies, adverse events and

monitoring guidelines

Skills be able to perform an effective musculoskeletal assessment of the

child or young person which takes into account their developmental

stage and growth

be able to take an appropriate musculoskeletal history from a child

or young person and their parents or carers

be able to perform effective musculoskeletal screening (e.g.pGALS)

and regional musculoskeletal examinations (e.g. pREMS)

be able to recognise the presentation of infection in the patient who

is immuno-compromised as a result of severe rheumatic disease

and / or treatment

be able to recognise clinical features in the presentation which

suggest serious pathology, such as inflammation, malignancy,

infection and vasculitis, and macrophage activation syndrome (as a



recognised complication of rheumatic disease)

be able to recognise features in the presentation or investigation of

a musculosketetal condition which suggest physical abuse,

emotional abuse and neglect, including possible fabricated illness

or failure to engage in clinic attendences / treatment

be able to tailor history taking for adolescents to account for

adolescent-specific issues such as risk-taking behaviours, and non

adherence to medication.

be able to appropriately triage inflammatory causes of joint and

back pain and facilitate referral to specialist paediatric teams as

necessary

recognise when to request the opinion of a paediatric

rheumatologist or orthopaedic surgeon

be able to formulate a differential diagnosis for children and young

people presenting with musculo-skeletal features including

mechanical and inflammatory causes of joint and back pain

be able to formulate an appropriate plan of initial investigation

based on the differential diagnosis

be able to interpret investigations that have been requested to

establish the differential diagnosis in the child or young person with

suspected rheumatic disease

be able to interpret the investigations used to assess and monitor

the child with a range of rheumatological conditions to monitor for

evolving multi-system involvement

demonstrate experience of the implementation and use of

immunosuppressive medications

be able to recognize the presentation of both generalized idiopathic

pain syndromes and complex regional pain syndromes

Leadership and Management

understand the role of the multidisciplinary team (including nurses

and physical therapists) and other professionals involved in the care

of children with a spectrum of musculoskeletal conditions



be aware of and have experience of the development of local

shared care guidelines within a clinical network

Membership of British Society for Paediatric and Adolescent

Rheumatology

Teaching and Research

appropriate participation in the audit cycle and the role of clinical

audit in good clinical practice

involvement in collaborative multi-centre research is encouraged,

specifically to gain experience of both research ethics, research

governance and patient recruitment processes

Communication Skills in Paediatrics

be able to describe and explain to children, young people and their

parents or carers the rationale for immunosuppressive treatment in

terms they will understand

be able to counsel children, adolescents and parents in the use and

monitoring of the potent immunosuppressive agents used in chronic

inflammatory diseases

be able to counsel children, adolescents and parents in issues

regarding chronic pain and fatigue



Section 3 Practical Procedures and Investigations in Paediatric Rheumatology

Practical Procedures and Investigations By the end of Special Interest Training in Paediatric Rheumatology, you will:

know the indications for the various techniques initially used in the

diagnosis and assessment of rheumatic diseases (radiographs,

ultrasound, CT and MRI scans)

know the indications and complications of joint aspiration and

corticosteroid injection and appropriate analgesia/anaesthesia

including the use of inhaled analgesia (e.g. Entonox) and general

anaesthesia

Pharmacology and Therapeutics

By the end of Special Interest Training in Paediatric Rheumatology, you will:

know the short and long term side effects of corticosteroids on the

musculoskeletal system and be aware of strategies to minimize

toxicity understand the indications and contraindications for potent

immunosuppressive agents including biologic agents used in severe

rheumatic disease in accordance with national/international

guidelines

know the common adverse events associated with disease

modifying drugs, monitoring schedules required and associated

advice on issues such as vaccinations / infection risk / pregnancy

Appendix 1



Paediatric Standards ChecklistThese standards were derived to assist in the assessment of the paediatric training

standards in your deanery

Speciality: Special Interest Module in Paediatric Rheumatology

The Programme (which may consist of several posts) shouldprovide:1. Supervision /1.1 An educational supervisor that is a Consultant (Paediatric Rheumatologist or General Paediatrician with expertise in Rheumatology working as part of a regional network ) trained in assessment and appraisal 1.2 An educational supervisor who provides an average of 1 PA per 4 trainees per week of educational supervision1.3 Evidence that the assessment strategy is being delivered1.4 Trainers receive appropriate training on the delivery of the assessment strategy

2. Other Personnel2.1 Paediatric Rheumatology Consultant to support and supervise and/or a Consultant General Paediatrician with expertise in Rheumatology working as part of a regional network2.2 More than one ST4 -8 in the general paediatric department overall 2.3 MDT consisting of a minimum of a specialist paediatric clinical nurse, a physiotherapist and an occupational therapist

3. Service requirements and facilities3.1 Specialty specific requirements of subspecialty department:

3.2 Specialty specific requirements of related clinical departments that are involved in delivery of the curriculum:Primary Care, Community Paediatrics, PICU, ophthalmology and eye screening and spectrum of sub-specialities 3.3 Specialty specific requirements of service departments relevant to delivery of curriculum (e.g. investigation departments, PAMs departments, surgery or anaesthesia):Day case facilities for joint injections and drug administration, imaging, and physical therapy. Opportunities for training and not simply a ‘service’ department.3.4 Specialty specific requirements of clinical networks:Opportunity to work within shared care networks in primary and secondary care. To include drug monitoring and shared care clinical guidelines and protocols



4. Educational activities and training4.1 Specialty specific clinical exposure required to provide sufficient learning opportunities(NB if giving workload data ensure it is explicit whether this is number per annum or number trainee would be expected to be exposed to over entire programme):Counselling of patients and carers about the use of biological and cytotoxic therapiesExperience of transitional care and adolescent services to adult rheumatology clinics.Experience of managing in-patients (eg acute presentation of SoJIA/lupus). Experience of multidisciplinary team working and multidisciplinary clinics4.2 Specialty specific requirements for structured training opportunities to include courses: This may include opportunites for training in joint injections (not expected to complete all joint injections listed for grid training, but may include knee injections for example provided there is an appropriate environment with paediatric anaesthesia / theatre), Good Clinical Practice training / research modules, teacher / management training, adolescent and transition training.. Expected to be able to attend British Society for Paediatric and Adolescent Rheumatology / clinical network / other paediatric rheumatology meetings for CPD and networking.

4.3 Specialty specific requirements for other experiential learning(excluding clinics and ward rounds):Joint injection skills - the general paediatrician with an interest in rheumatology is not expected to be competent in joint injection techniques for all joints but should be able to competently aspirate and inject knees, using either general anaesthetic or inhaled anaesthesia

5. Working patterns5.1 Safe cover arrangements for paediatric department out of hours in line with RCPCH guidance 5.2 Evidence of compliance with existing employment rules to working time 5.3 Working intensity and pattern that is appropriate for learning5.4 Access to sub-specialty training time which allows achievement of the competences throughout the programme5.5 This post forms part of a complete paediatric training programme which provides a minimum of 5 years of acute clinical experience, including out of hours

6. Specific Post requirements6.1 12 months working within tertiary rheumatological services or within a clinical network with a regional paediatric rheumatology centre.



7. Enabled to learn new skills, necessary skills and curriculum coverage (speciality specific)This section can be used to highlight marker conditions to which trainee should be exposed or the numbers of cases/procedures that trainee will be expected to see/do. Ensure that it is clear whether any numbers are for whole training programme or per annum7.1 Specialty specific marker conditions trainee should be exposed to:Paediatric rheumatology training emphasises the importance of experiencing the spectrum of rheumatic disease, both mechanical and inflammatory, acute and chronic and range of severity from mild disease to those with multi-system/organ involvement. In addition, as children move into adolescence and the need for transition arises, trainees are expected to develop adolescent-specific skills and understand how to plan and facilitate transition. Competencies and knowledge will be assessed as part of revalidation.

8. Access to clinics and ward rounds and long term care of patients

8.1 Specialty specific numbers and types of clinics expected to attend (including outreach clinics):Regular access to supervised clinics to include new and review patients eg >/= 1 OP clinic per week; general rheumatology experience as well as exposure to patients with connective tissue disease / vasculitis / multi-sytem inflammatory disease

8.2 Specialty specific combined clinics expected to attend:Regular access to combined clinics with appropriate sub-specialties8.3 Specialty specific ward rounds consultant led and independent per week: recommended at least one consultant led and one independent ward round per week

8.4 Specialty specific involvement in transitional care: provision to facilitate transfer to adult rheumatology. Required to have experience of adolescent and young adult rheumatology including attendance at a formal transition / adult clinic.

9. Meetings9.1 Specialty specific number and types of MDT meetings expected to be exposed to:Attend and participate in weekly multi-disciplinary team meetings9.2 Specialty specific multi-professional meetings expected to be exposed to:Attend regional and Rheumatology interest groups Attendance and membership of British Society for Paediatric and Adolescent Rheumatology

10. Clinical audit 10.1 Participate in clinical audit



11. Teaching appraising and assessing11.1 Opportunities for formal and informal teaching11.2 For senior trainees: opportunities for involvement of assessment of others11.3 For senior trainees: opportunity to be involved in the appraisal of others

12. Research12.1 involvement in collaborative multi-centre research and in particular NIHR portfolio activities / Arthritis Research UK / MCRN Clinical Studies Group paediatric rheumatology activities and provide patients with opportunities to engage in clinical trials

13. ManagementExperience in leadership skills / organisational issues

X-ref Comments



Appendix 2

Assessment Guidance

***The Education & Training Division of the RCPCH has been reviewing the

current Workplace Based Assessments. The outcome of this review, which

had approval from the GMC on 1st July 2013, will see the introduction of a

one year national pilot from September 2013, to be completed by October

2014, to assess and evaluate these adaptations. New Directly Observed

Procedural Skills (DOPS), Mini Clinical Evaluation Exercise (Mini-CEX), and

Case Based Discussion (CbD) forms will be introduced onto ASSET from

September and are amendments to the current format. Mini CeX and CbDs

will take the format of Supervised Learning Events (SLEs), similar in format to

those introduced in the Foundation Programme. DOPs will become

summative in nature.The new Handover Assessment Tool (HAT), Leader tool

and a paediatric specific Acute Care Assessment Tool (ACAT), will be

introduced in October 2013. Discussion of Communication (DOC) will be

introduced to replace the current SAIL assessment. Paediatric trainees are

advised to regularly check the RCPCH website for further information how to

carry out these new assessments and what will be expected from those

involved in the process. ***

Within the current work based assessment requirements for Level 3 training, paediatric trainees undertaking the special interest module of assessment are recommended to undertake the minimum number of assessments specially related to paediatric rheumatology :

Paediatric Case Based Discussion (ePaedCbD): 4 per year

Paediatric Mini Clinical Evaluation Exercise (ePaedMiniCeX): 2 per year

Directly Observed Procedure Skills (DOPS): 1 per relevant procedure

Sheffield Assessment Instrument for Letters (SAIL): 3 per year

Multi-Source Feedback (ePaedMSF): 1 per year

(as part of appraisal / revalidation process)



Content of work based assessments

ePaedMiniCeX suggestions include clinic assessment and communication

with parents/ carers on starting DMARD/ biologic, mechanical pain/ BJHS.

ePaedCbD suggestions include differential diagnosis and appropriate

management plans. psycholoscial aspects, child protection, transition to adult

services and long term prognosis, with topics such as New Diagnosis JIA/

Systemic Onset/ Vasculitis/ Mechanical , MSK/ Back Pain/ Hypermobility

DOPS to include intra articular steroid injection to a knee under general

anaesthetic and entonox (assessed and passed as compentent to perform

without supervision) . Discussion at time of DOPS to include

Choice of intra articular steroid and dosage

Consent and adverse events

Preparation of patient

Aseptic technique

SAIL - To assess written communication skills, including importance of

shared care with colleagues in local networks

ePaedMSF - Include feedback from at least 12 health professionals

(consultants, seniors, peers, junior doctors, nurses, allied health professionals

from paediatric rheumatology as well as general paediatrics) to provide

feedback via ASSET on work performance.


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