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Royal College of Physicians and Surgeons of Canada

Objectives of Training in the Subspecialty of Adult and Pediatric Rheumatology

2011

EDITORIAL REVISION – APRIL 2015
VERSION 1.2

This document applies to those who begin training on or after July 1st, 2011.

DEFINITION

Rheumatology is the branch of medicine concerned with the specialized assessment and care of patients with rheumatological, autoimmune, and related musculoskeletal health disorders. Traditionally, pediatric patients are attended to by Pediatricians with subspecialty training in pediatric Rheumatology. Adult patients are attended to by Internists with subspecialty training in adult Rheumatology.

GOALS

On completion of the educational program, the graduate physician will be competent to function as a consultant rheumatologist. This requires the physician to be effective in the assessment, investigation, management, and rehabilitation of patients with acute and chronic forms of arthritis, soft tissue rheumatologic disorders, collagen-vascular diseases and vasculitides, spinal and regional pain problems and the musculoskeletal manifestations of systemic disease.

Residents in Rheumatology may plan a residency program directed to a future career ranging from independent private practice in the community to an academic administrative, teaching and/or research career in the university setting. Residents wishing to pursue a career in academic Rheumatology are encouraged to take additional research training following completion of the core clinical Rheumatology program.

Only candidates certified by the Royal College of Physicians and Surgeons of Canada in Internal Medicine or Pediatrics may be eligible for certification in Rheumatology.

Residents must demonstrate the requisite knowledge, skills, and attitudes for effective patient-centred care and service to a diverse population. In all aspects of specialist practice, the graduate must be able to address ethical issues and issues of gender, sexual orientation, age, culture, beliefs, and ethnicity in a professional manner.

RHEUMATOLOGY COMPETENCIES

At the completion of training, the resident will have acquired the following competencies and will function effectively as a:

Medical Expert

Definition:

As Medical Experts, Rheumatologists integrate all of the CanMEDS Roles, applying medical knowledge, clinical skills, and professional attitudes in their provision of patient-centred care. Medical Expert is the central physician Role in the CanMEDS framework.

Key and Enabling Competencies: Rheumatologists are able to…

  1. Function effectively as consultants, integrating all of the CanMEDS Roles to provide optimal, ethical and patient and/or family-centred medical care
    1. Perform a consultation, including the presentation of well-documented assessments and recommendations in oral, written, and/or electronic form from another health care professional
    2. Demonstrate use of all CanMEDS competencies relevant to Rheumatology
    3. Identify and appropriately respond to relevant ethical issues arising in patient care
    4. Demonstrate the ability to prioritize professional duties when faced with multiple patients and problems
    5. Demonstrate compassionate patient-centred and family-centred care
    6. Recognize and respond to the ethical dimensions in medical decision-making
    7. Demonstrate medical expertise in situations other than patient care, such as providing expert legal testimony, educating patients, referring physicians, or advising governments, as needed
  2. Establish and maintain clinical knowledge, skills and behaviours appropriate to the practice of Rheumatology
    1. Apply knowledge of the clinical, socio-behavioural, and fundamental biomedical sciences relevant to Rheumatology
      1. Basic and epidemiologic science
        1. Anatomy and physiology of bone, joints, connective tissue, blood vessels and muscle in health and disease
          1. Mechanism of joint deformities and structural abnormalities in rheumatic disease
        2. Genetic contributions to rheumatic disease
          1. Human Leukocyte Antigen (HLA) genes
          2. Non-HLA genes
          3. Single nucleotide polymorphisms
        3. Immune and inflammatory responses relevant to pathogenesis of rheumatologic diseases and the therapeutic strategies used for their management
          1. Immunologic techniques
          2. Acute phase response
          3. Innate immunity
          4. Adaptive immunity
            1. Complement
            2. Major Histocompatibility Complex (MHC) and antigen presentation
            3. T cell development and activation
            4. B cell development and activation
            5. Auto-antibodies
          5. Cytokines and chemokines
          6. Central and peripheral tolerance
        4. Purine metabolism (adult Rheumatology only)
        5. Pharmacology of therapeutic agents in rheumatic disease
        6. Epidemiological methods in the study of rheumatic disease
        7. Neurobiology of pain
      2. Demonstrate in depth knowledge of the following, for the conditions listed, relevant to adult and pediatric Rheumatology:
        1. Natural history
        2. Epidemiology
        3. Pathogenesis
          1. Genetics
          2. Immunology
        4. Clinical presentation (typical and atypical) and diagnosis
        5. Classification criteria
        6. Complications
        7. Investigations
          1. Laboratory and immunological markers
            1. Synovial fluid analysis
          2. Diagnostic imaging
          3. Pathology
        8. Outcome measures including but not lmited to economic and social consequences, disability assessment and disease activity
    2. Adult Rheumatology

      1. Inflammatory arthritis
        • Rheumatoid arthritis
        • Spondyloarthritides
        • Crystal arthritis
        • Infectious arthritis
        • Infection–related arthropathies
        • Periodic arthritis syndromes
        • Adult onset Still’s disease and macrophage activation syndrome
      2. Connective tissue disease
        • Systemic lupus erythematosis and other lupus entities
        • Scleroderma (limited and diffuse)
        • Linear scleroderma
        • Sjogren’s syndrome
        • Inflammatory myopathies
        • Antiphospholipid antibody syndromes
        • Relapsing polychondritis
      3. Vasculitides
        • Giant cell arteritis/polymyalgia rheumatica
        • Takayasu’s arteritis
        • Polyarteritis nodosa - classic
        • Anti-neutrophil cytoplasmic antibody(ANCA) -associated vasculitides
        • Cryoglobulinemia
        • Isolated cutaneous vasculitis
        • Undifferentiated vasculitis
        • Behcet’s disease
        • Primary central nervous system (CNS) vasculitis
      4. Osteoarthritis
      5. Metabolic and idiopathic bone disease
        • Osteoporosis
        • Osteomalacia
        • Renal osteodystrophy
        • Paget’s disease
        • Diffuse idiopathic skeletal hyperostosis (DISH)
        • Hypertrophic osteoarthropathy
      6. Non-articular Rheumatism
        • Fibromyalgia
        • Myofascial pain syndromes
        • Complex regional pain syndrome
      7. Regional musculoskeletal disorders
        • Bursitis, enthesitis, tendonopathies
      8. Environment related disease
        • Overuse syndromes
      9. Non-inflammatory myopathies
        • Metabolic and endocrine related myopathies
        • Drug and toxin induced myopathy
        • Muscular dystrophies
      10. Rheumatological manifestations of chronic medical illnesses
      11. Tumors of bone, synovium
      12. Osteonecrosis
      13. Sarcoidosis
      14. Uveitis
      15. Ochronosis
      16. Pregnancy and rheumatological disease
      17. Hereditary, congenital and inborn errors of metabolism
        • Marfan’s syndrome
        • Ehlers-Danlos syndrome
        • Hypermobility
      18. Pediatric rheumatological diseases
        • Juvenile idiopathic arthritis (JIA)
        • Connective tissue diseases (including linear scleroderma)
        • Periodic fever / autoinflammatory syndromes
        • Vasculitides especially Kawasaki and Henoch Schonlein Purpura
        • Juvenile dermatomyositis
        • Neonatal lupus
        • Juvenile chronic regional pain syndromes
        • Inflammatory bone disease (chronic non-bacterial osteomyelitis)

      Pediatric Rheumatology

      1. Juvenile arthritis (JIA)
      2. Juvenile spondyloarthritis
      3. Systemic lupus erythematosus
      4. Neonatal lupus
      5. Mixed connective tissue disease (MCTD)/undifferentiated connective tissue disease/overlap syndrome
      6. Scleroderma (localized, limited and diffuse)
      7. Raynaud’s phenomenon
      8. Sjogren’s syndrome
      9. Antiphospholipid antibody syndromes (primary and secondary)
      10. Inflammatory and non-inflammatory myopathies
      11. Sarcoidosis
      12. Vasculitides
        • Kawasaki disease
        • Henoch Schonlein Purpura (HSP)
        • Takayasu’s arteritis
        • Polyarteritis odosa –cutaneous and systemic
        • ANCA-associated vasculitides
        • Cryoglobulinemia
        • Primary CNS vasculitis
        • Undifferentiated vasculitis
        • Behcet’s disease
        • Hypersensitivity vasculitis
      13. Uveitis
      14. Pain and pain amplification syndromes
      15. Arthritis related to infection
        • Acute rheumatic fever/poststreptococcal reactive arthritis
        • Reactive arthritis
        • Lyme disease
        • Infectious arthritis and osteomyelitis
      16. Periodic Ffver/autoinflammatory syndromes
      17. Inflammatory bone disease
        • Chronic non-bacterial osteomyelitis
      18. Osteoporosis/metabolic bone disease
      19. Mechanical, developmental or structural abnormalities
      20. Congenital and acquired Immunodeficiencies and rheumatic disease
      21. Skeletal malignancies and related disorders
      22. Primary disorders of bone and connective tissue, including:
        • Marfan syndrome
        • Ehlers-Danlos syndrome
        • Hypermobility
        • Skeletal and osteochondrodysplasias
      23. Rheumataological manifestations of systemic diseases
        • Hematologic disorders, including:
          • Hemophilia
        • Genetic syndromes, including:
          • Trisomy 21
        • Disorders of endrocrine/exocrine glands, including:
          • Diabetes
          • Cystic fibrosis (CF)
        • Metabolic disorders, including but not limited to nutritional abnormalities
        • Inflammatory bowel disease
        • Celiac disease
        • Miscellaneous conditions:Macrophage activation syndrome
        • Polychondritis
        • Hyperostosis
        • Autoimmue lymphoproliferative syndrome or other genetic-related rheumatological disorders
    3. Describe the CanMEDS framework of competencies relevant to Rheumatology
    4. Apply lifelong learning skills of the Scholar Role to implement a personal program to keep up to date, and enhance areas of professional competence
    5. Integrate the available best evidence and best practices to enhance the quality of care and patient safety in Rheumatology
  3. Perform a complete and appropriate assessment of a patient
    1. Identify and effectively explore issues to be addressed in a patient encounter, including the patient’s context and preferences
    2. Elicit a history that is relevant, concise, and accurate to context and preferences, for the purposes of diagnosis, management, health promotion, and disease prevention
    3. Perform a focused physical examination that is relevant and accurate, for the purposes of diagnosis, management, health promotion, and disease prevention. These skills should include but are not limited to the following:
      1. Measures of disease activity
      2. Measures of tissue damage and deformity
      3. Functional assessment and quality of life
    4. Select medically appropriate investigative methods in a evidence-based, resource-effective and ethical manner
      1. Demonstrate knowledge of the scientific basis, indications/contraindications, limitations and clinical interpretation of:
        1. Specialized immunological and serologic investigations
        2. Joint aspiration and synovial fluid analysis
        3. Tissue biopsies
        4. Electromyography and nerve conduction studies
        5. Diagnostic imaging of joint and musculoskeletal diseases
    5. Demonstrate effective clinical problem solving and judgment to address patient problems, including interpreting available data and integrating information to generate differential diagnoses and management plans
  4. Use preventive and therapeutic interventions effectively
    1. Implement a management plan in collaboration with a patient and their family
    2. Demonstrate appropriate and timely application of preventive and therapeutic interventions relevant to the practice of Rheumatology
      1. Non pharmacological therapy
      2. Pharmacologic and biologic therapy [including plasma exchange and Intravenous Immunoglobulin (IVIg)]
      3. Joint and soft tissue injections
      4. Complementary medicine
    3. Obtain appropriate informed consent for therapies
    4. Ensure patients receive appropriate end-of-life care
      1. Demonstrate support of the patient and family as appropriate
  5. Demonstrate proficient and appropriate use of procedural skills, both diagnostic and therapeutic
    1. Demonstrate effective, appropriate, and timely performance of diagnostic and therapeutic procedures relevant to Rheumatology, including joint and soft tissue aspiration and/or injections and synovial fluid analysis, including accurate use of polarized microscopy for crystal analysis, as needed
      1. For those training in Adult Rheumatology, arthrocentesis and injection of the following:
        1. Shoulders, elbows, wrists and metacarpalphalangeals
        2. Knees, ankles and metatarsophalangeal
        3. Soft tissue injections
        4. Flexor tendon sheaths – e.g. bicipital, palmar
        5. Plantar fascia, medial and lateral epicondyle
        6. Bursae – e.g. subacromial, trochanteric, anserine
      2. For those training in Pediatric Rheumatology, arthrocentesis and injection of the following in children and adoloscents:
        1. Shoulders, elbows, wrists and metacarpalphalangeals
        2. Knees, ankles and metatarsophalangeals
        3. Flexor tendon sheaths
        4. Bursae
      3. Demonstrate knowledge of the indications and contraindications for sedation and analgesia as required for patients undergoing rheumatologic procedures
      4. Demonstrate knowledge for the indications and appropriate use of image-guidance in arthrocentesis and injection.
    2. Obtain appropriate informed consent for procedures
    3. Document and disseminate information related to procedures performed and their outcomes
    4. Ensure adequate followup is arranged for procedures performed
  6. Seek appropriate consultation from other health professionals, recognizing the important contributions of the multidisciplinary team members in the care of patients with arthritis-related conditions including but not limited to nurses, physiotherapists, occupational therapists, social workers, dieticians, and pharmacists)
    1. Demonstrate insight into their own limits of expertise
    2. Demonstrate effective, appropriate, and timely consultation of another health professional, as needed for optimal patient care
    3. Arrange appropriate followup care services patients and their families/caregivers

Communicator

Definition:

As Communicators, Rheumatologists effectively facilitate the doctor-patient relationship and the dynamic exchanges that occur before, during, and after the medical encounter.

Key and Enabling Competencies: Rheumatologists are able to…

  1. Develop rapport, trust, and ethical therapeutic relationships with patients and families
    1. Recognize that being a good communicator is a core clinical skill for physicians, and that effective physician-patient communication can foster patient satisfaction, physician satisfaction, adherence, and improved clinical outcomes
    2. Establish positive therapeutic relationships with patients and their families that are characterized by understanding, trust, respect, honesty, and empathy
    3. Respect patient privacy, confidentiality, and autonomy
    4. Listen effectively
    5. Be aware of and responsive to nonverbal cues
    6. Facilitate a structured clinical encounter effectively
  2. Accurately elicit and synthesize relevant information and perspectives of patients and families, colleagues, and other professionals
    1. Gather information about a disease and about a patient’s beliefs, concerns, expectations, and illness experience
    2. Seek out and synthesize relevant information from other sources, such as a patient’s family, caregivers, and other professionals, while respecting individual privacy and confidentiality
  3. Convey relevant information and explanations accurately to patients and families, colleagues, and other professionals
    1. Deliver information to a patient and family, colleagues, and other professionals in a humane manner and in such a way that it is understandable and encourages discussion and participation in decision-making
  4. Develop a common understanding on issues, problems, and plans with patients, families, and other professionals to develop a shared plan of care
    1. Identify and effectively explore problems to be addressed from a patient encounter, including the patient’s context, responses, concerns, and preferences
    2. Respect diversity and differences, including but not limited to the impact of gender, religion, and cultural beliefs on decision-making
    3. Encourage discussion, questions, and interaction in the encounter
    4. Engage patients, families, and relevant health professionals in shared decision-making to develop a plan of care relevant to acute and chronic rheumatologic, connective tissue, or musculoskeletal disorders
    5. Address challenging communication issues effectively, including but not limited to obtaining informed consent, delivering bad news, and addressing anger, confusion and misunderstanding
  5. Convey oral, written, and/or electronic information effectively about a medical encounter
    1. Maintain clear, concise, accurate, and appropriate records of clinical encounters and plans
    2. Present oral reports of clinical encounters and plans
    3. Convey medical information appropriately to ensure safe transfer of care
  6. Present medical information effectively to the public about a medical issue

Collaborator

Definition:

As Collaborators, Rheumatologists effectively work within a health care team to achieve optimal patient care.

Key and Enabling Competencies: Rheumatologists are able to…

  1. Participate effectively and appropriately in an interprofessional health care team most often associated with Rheumatology, including but not limited to physical therapists, occupational therapists, nurses, pharmacists, orthopedic surgeons and primary care providers
    1. Describe the Rheumatologist’s roles and responsibilities to other professionals
    2. Describe the roles and responsibilities of other professionals within the health care team
    3. Recognize and respect the diverse roles, responsibilities, and competences of other professionals in relation to their own
    4. Work with others to assess, plan, provide, and integrate care for individuals and groups of patients
    5. Work collaboratively in other activities and tasks; examples are research, educational work, program review, and/or administrative responsibilities
    6. Participate in interprofessional team meetings
    7. Enter into interdependent relationships with other professions for the provision of quality care
    8. Describe the principles of team dynamics
    9. Respect team ethics, including confidentiality, resource allocation, and professionalism
    10. Demonstrate leadership in a health care team, as appropriate
  2. Work with other health professionals effectively to prevent, negotiate, and resolve interprofessional conflict
    1. Demonstrate a respectful attitude towards colleagues and members of an interprofessional team
    2. Work with other professionals to prevent conflicts
    3. Respect differences and the scopes of practice of other professions
    4. Reflect on their own differences, misunderstandings, and limitations that may contribute to interprofessional tension
    5. Reflect on interprofessional team function
    6. Employ collaborative negotiation to resolve conflicts and address misunderstandings

Manager

Definition:

As Managers, Rheumatologists are integral participants in health care organizations, organizing sustainable practices, making decisions about allocating resources, and contributing to the effectiveness of the health care system.

Key and Enabling Competencies: Rheumatologists are able to…

  1. Participate in activities that contribute to the effectiveness of their health care organizations and systems
    1. Work collaboratively with others in their organizations
    2. Participate in systemic quality process evaluation and improvement, including patient safety initiatives
    3. Describe the structure and function of the health care system as it relates to Rheumatology, including the roles of physicians
    4. Describe principles of health care financing with particular emphasis on the interface of private and public health care in Canada, drug/benefit coverage and models of physician remuneration, as it pertains to Rheumatology
  2. Manage their practice and career effectively
    1. Set priorities and manage time to balance patient care, practice requirements, academic activities, continuing medical education, and personal life
    2. Manage a practice, including finances and human resources
    3. Implement processes to ensure personal practice improvement
    4. Employ information technology appropriately for patient care
  3. Allocate finite health care resources appropriately
    1. Demonstrate an understanding of the importance of just allocation of health care resources, balancing effectiveness, efficiency, and access with optimal patient care
    2. Apply evidence and management processes for cost-appropriate care
  4. Serve in administration and leadership roles
    1. Participate effectively in committees and meetings
    2. Lead or implement change in health care
    3. Plan relevant elements of health care delivery, such as work schedules

Health Advocate

Definition:

As Health Advocates, Rheumatologists responsibly use their expertise and influence to advance the health and well-being of individual patients, communities, and populations.

Key and Enabling Competencies: Rheumatologists are able to…

  1. Respond to individual patient health needs and issues as part of patient care
    1. Identify the health needs of an individual patient
    2. Identify opportunities for advocacy, health promotion, and disease prevention with individuals to whom they provide care
    3. Demonstrate an appreciation of the possibility of competing interests between individual advocacy issues and the community at large
    4. Describe the impact of musculoskeletal conditions on function and participation in work, school and social settings
      1. 1.4.1. ormulate plans for return to work or school for patients with musculoskeletal conditions or other rheumatic diseases
    5. Assist patients in obtaining appropriate benefits when disabled
  2. Respond to the health needs of the communities that they serve
    1. Describe the practice communities that they serve
    2. Identify opportunities for advocacy, health promotion, and disease prevention in the communities that they serve, and respond appropriately including but not limited to working with The Arthritis Society, the Canadian Rheumatology Association, Canadian Pediatric Society, and other age and disease-specific patient advocacy groups, as relevant to Rheumatology
    3. Demonstrate an appreciation of the possibility of competing interests between the communities served and other populations
  3. Identify the determinants of health for the populations that they serve, particularly as they relate to patients with chronic musculoskeletal and connective tissue disorders
    1. Identify the determinants of health of the population, including barriers to access to care and resources
    2. Identify vulnerable or marginalized populations within those served and respond appropriately
  4. Promote the health of individual patients, communities, and populations
    1. Describe an approach to implementing a change in a determinant of health of the populations they serve
    2. Describe how public policy can impact on the health of the populations served
    3. Identify points of influence in the health care system and its structure
    4. Describe the ethical and professional issues inherent in health advocacy, including conflict of interest, altruism, social justice, autonomy, integrity, and idealism
    5. Demonstrate an appreciation of the possibility of conflict inherent in their role as a health advocate for a patient or community with that of manager or gatekeeper
    6. Describe the role of the medical profession in advocating collectively for health and patient safety

Scholar

Definition:

As Scholars, Rheumatologists demonstrate a lifelong commitment to reflective learning, as well as the creation, dissemination, application and translation of medical knowledge.

Key and Enabling Competencies: Rheumatologists are able to…

  1. Maintain and enhance professional activities through ongoing learning
    1. Describe the principles of maintenance of competence
    2. Describe the principles and strategies for implementing a personal knowledge management system
    3. Recognize and reflect on learning issues in practice
    4. Implement a personal learning program to keep up-to-date, and enhance areas of professional competence
    5. Conduct personal practice audits
    6. Pose an appropriate learning question
    7. Access and interpret the relevant evidence
    8. Integrate new learning into practice
    9. Evaluate the impact of any change in practice
    10. Document the learning process
  2. Critically evaluate medical information and its sources, and apply this appropriately to practice decisions
    1. Describe the principles of critical appraisal as they pertain to rheumatologic literature, recognizing the challenges involved in the study of rare diseases, small populations, and complex outcome measures, including:
      1. Levels of Evidence
      2. Consensus building tools, including but not limited to guidelines
    2. Critically appraise retrieved evidence in order to address a clinical question
    3. Integrate critical appraisal conclusions into clinical care
  3. Facilitate the learning of patients, families, students, residents, other health professionals, the public, and others, as appropriate
    1. Describe principles of learning relevant to medical education
    2. Identify collaboratively the learning needs and desired learning outcomes of others
    3. Select and demonstrate effective teaching strategies and content to facilitate others’ learning
    4. Deliver effective lectures or presentations
    5. Assess and reflect on a teaching encounter and incorporate change based on feedback
    6. Provide effective feedback
    7. Describe the principles of ethics with respect to teaching
  4. Contribute to the development, dissemination, and translation of new knowledge and practices
    1. Describe the principles of research and scholarly inquiry
    2. Describe the principles of research ethics
    3. Pose a scholarly question as it relates to Rheumatology
    4. Conduct a systemic search for evidence
    5. Select and apply appropriate methods to address the question
    6. Demonstrate awareness of the diversity of mechanisms available to appropriately disseminate the findings of a study, and participate in one mode of dissemination
    7. Participate in a scholarly research, quality assurance, or educational project relevant to Rheumatology, demonstrating primary responsibility for at least one of the following elements of the project:
      1. Development of the hypothesis, which must include a comprehensive literature review
      2. Development of the protocol for the scholarly project
      3. Preparation of a grant application
      4. Development of the research ethics proposal
      5. Interpretation and synthesis of the results

Professional

Definition:

As Professionals, Rheumatologists are committed to the health and well-being of individuals and society through ethical practice, profession-led regulation, and high personal standards of behaviour.

Key and Enabling Competencies: Rheumatologists are able to…

  1. Demonstrate a commitment to their patients, profession, and society through ethical practice
    1. Exhibit appropriate professional behaviours in practice, including honesty, integrity, commitment, compassion, respect and altruism
    2. Demonstrate a commitment to delivering the highest quality care and maintenance of competence
    3. Recognize and appropriately respond to ethical issues encountered in teaching, research, and clinical practice
      1. Demonstrate consistent knowledge of the principles of medical ethics as they relate to patient care including concepts of autonomy, beneficence, nonmaleficence, confidentiality, truth-telling, justice, respect for persons, conflict of interest and resource allocation
      2. Demonstrate consistent application of medical ethics as they relate to patient care including autonomy, beneficence, nonmaleficence, confidentiality, truth-telling, justice, respect for persons, conflict of interest and resource allocation
      3. Demonstrate consistent application of clinical research ethics as described in the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans including conflict of interest, informed consent and patient confidentiality
      4. Demonstrate consistent application of ethical behaviour in teaching including patient confidentiality, teacher-learner relationship and fairness of evaluation
    4. Identify, declare, and appropriately manage perceived, potential, and actual conflicts of interest
    5. Recognize the principles and limits of patient privacy and confidentiality, as defined by the law and professional practice standards
    6. 1.6. Maintain appropriate boundaries with patients
  2. Demonstrate a commitment to their patients, profession, and society through participation in profession-led regulation
    1. Describe the CanMEDS framework of competencies relevant to Rheumatology
    2. Demonstrate knowledge and an understanding of professional, legal, and ethical codes of practice
    3. Fulfill the regulatory and legal obligations required of current practice
    4. Demonstrate accountability to professional regulatory bodies
      1. Demonstrate a willingness to accept peer and supervisor reviews of professional competence
      2. Demonstrate recognition of personal limitations of professional competence and demonstrate a willingness to call upon others with special expertise
      3. Demonstrate flexibility and willingness to adjust to changing circumstances
    5. Recognize and respond appropriately to others’ unprofessional behaviours in practice
    6. Participate in peer review
  3. Demonstrate a commitment to physician health and sustainable practice
    1. Balance personal and professional priorities to ensure personal health and a sustainable practice
    2. Strive to heighten personal and professional awareness and insight
    3. Recognize other professionals in need and respond appropriately

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This HTML version of the national standard document was created for compliance to AODA standards. The official Royal College version is the PDF version which you may access by clicking on the PDF Print Version below. The PDF version will be used for all Royal College related business (credentialing, accreditation, assessment etc.) and therefore, if there are any discrepancies between the PDF version and this HTML version, the PDF is the accurate approved Royal College standard.