Abstract
Objective
Adult rheumatology fellowships’ curricular needs are changing following the COVID‐19 pandemic. The American College of Rheumatology's (ACR's) Virtual Program for Fellows‐in‐Training (FITs), initially developed to maintain didactic instruction while sheltering in place, has suffered decreased attendance in recent years. We describe the evolving curricular needs of adult rheumatology fellowship programs and FITs as well as suggest opportunities for the ACR to address them.
Methods
Adult rheumatology fellowship program directors (PDs) in the United States and Canada were invited to describe how they used the ACR Virtual Program for FITs, their perceived challenges with the programming, and curricular needs via online surveys. PDs and FITs shared ideas for future ACR Virtual Programs for FITs via surveys and focus groups. We conducted descriptive statistics of survey data and qualitative analysis of focus group transcripts.
Results
Of 123 PDs, 17 (13.8%) completed the survey, and 8 PDs and 6 FITs participated in five focus groups. Of 17 PDs, 7 (41%) reported insufficient resources to create a comprehensive curriculum, and all respondents used the ACR Virtual Program for FITs to supplement clinical expertise and/or time available for teaching. Focus group participants requested that the ACR Virtual Program for FITs expand to advanced rheumatology topics, foster active learning methods while maintaining safety in learning, and make educational materials easily accessible to PDs and FITs.
Conclusion
Shared educational resources enhance adult rheumatology fellowships’ curricula. The ACR Virtual Program for FITs can meet changing curricular needs by expanding content, incorporating active learning, and sharing resources through easily accessible methods.
INTRODUCTION
A variety of experiences, including didactic sessions and patient encounters, form the curricula that teach rheumatology fellows‐in‐training (FITs) to deliver care to people with rheumatic diseases. 1 The American College of Rheumatology (ACR) Core Curriculum outlines requisite instructional content, and resources at fellowship training programs (“programs”) influence how content is delivered. 2 Therefore, the ACR Core Curriculum opens opportunities for sharing educational materials and perhaps supplementing wherever programs’ resources may be limited.
SIGNIFICANCE & INNOVATIONS.
The American College of Rheumatology (ACR) Committee on Training develops shared educational materials, including the adult Virtual Program for Fellows‐in‐Training (V‐FIT), that enhance the curricula of rheumatology fellowship training programs and support fellows’ preparedness for entering the workforce.
The educational needs of rheumatology fellowship training programs and fellows are changing following the resolution of the COVID‐19 pandemic, and ACR adult V‐FIT programming must adapt to meet these evolving needs.
Moving forward, ACR adult V‐FIT programming can best support rheumatology fellowship training programs and FITs by expanding curricular content to more advanced topics, integrating active learning strategies that maintain fellows’ sense of security during learning, and improving the accessibility of educational materials.
The ACR's Virtual Rheumatology Program for Fellows‐in‐Training (V‐FIT) exemplifies the impact of sharing materials. 3 Since 2020 when the COVID‐19 pandemic disrupted medical education, V‐FIT has sponsored three learning series for adult rheumatology FITs: Virtual Rheumatology Learning (ViRL, 2020), Virtual Rheumatology Practicum for Adult Fellows (ViP‐Adult, 2021–2024), and Virtual Rheumatology Teaching Lessons (ViTLs, 2021–2025). ViRL piloted the implementation of a national virtual learning program, whereas ViP‐Adult and ViTLs expanded ViRL's success, respectively delivering foundational and advanced topics in the ACR Core Curriculum that adult programs can incorporate into their curricula. Sessions present virtual lectures and question and answer segments with nationally recognized experts that foster learning interactions with fellow FITs, thought leaders, and the college itself. A survey of FITs and program directors (PDs) conducted in 2021 demonstrated that V‐FIT increased connection within the rheumatology community (94% FITs; 88% PDs) and addressed educational needs (97% FITs; 97% PDs), 3 signaling the benefits of learning with social interaction and sharing resources. 4
Despite V‐FIT's initial success, ViP‐Adult and ViTLs usage has declined with the return to in‐person learning. The average number of real‐time session viewers decreased from 74 attendees in 2020 to 27 attendees in 2023. This decline highlights the evolving needs of medical education, raising questions of how V‐FIT can best produce shared resources that optimize adult FITs’ learning. In this study, we surveyed adult FITs and PDs with the aim of assessing their curricular needs and exploring opportunities for future V‐FIT programming to support rheumatology curricula in the current landscape.
MATERIALS AND METHODS
Working group
The ACR Committee on Training assembled a V‐FIT Needs Assessment Working Group of medical educators with expertise in curricular design and research methods (DL, JA, LZ), a current (MDD) and recently graduated (LCA) adult FIT who attended V‐FIT sessions, and an ACR staff member who administered V‐FIT programming (JM). The working group applied mixed methodology, targeting adult FITs and PDs, to assess curricular needs.
Survey
The working group (LCA, MDD, DL, JM, LZ) developed a survey for adult rheumatology fellowship PDs, informed by social learning theory and the ACR Core Curriculum (Supplement 1).2,4,5 The survey aimed to (1) describe programs’ ability to create a fellowship curriculum with currently available resources; (2) determine barriers to using ViP‐Adult; and (3) assess opportunities for future programming that address curricular needs. Invitations to complete the survey were circulated to the ACR PD listserv in October 2024 and via announcements at the 2024 ACR Convergence Workforce & Education sessions. The survey was available electronically November to December 2024 through WashU Medicine's Qualtrics subscription with exempt research information sheets embedded within. We analyzed survey results with descriptive statistics. We planned to conduct chi square analysis to assess if the size of a program was associated with use of V‐FIT; however, response numbers limited reliability. We calculated the average size and geographic distribution of adult programs using data tracked by the ACR Committee on Training from the 2024 to 2025 academic year.
Focus groups
The working group (LCA, MDD, DL, JM, LZ) wrote interview guides for adult rheumatology fellowship PDs to share their opinions regarding ViP‐Adult. Questions further explored survey results and anecdotes commonly shared among PDs. Adult FITs and PDs were invited to participate in focus groups via ACR listservs (September 2024) and announcements at the Rheumatology Review Course (November 2024) and the ACR Educators’ Conference (March 2025). Focus groups were held on video teleconference November 2024 to April 2025, featuring either FITs (led by LCA and MDD) or PDs (led by LZ). We organized groups according to participants’ roles to enhance comfort sharing opinions. We continued hosting focus groups until no new concepts emerged from the discussions (saturation). Focus group leaders (MDD and LZ) obtained verbal consent and followed interview guides (Supplement 2) that surveyed use of V‐FIT and learning preferences, challenges with V‐FIT programming, and ideas for future directions. Discussions were recorded with WashU Medicine's subscription to Zoom and transcribed using Trint Transcription Services, both HIPAA (Health Insurance Portability and Accountability Act)–secure. Participants received a certificate of participation for their time.
Four researchers (LCA, MDD, JA, LZ) conducted conventional content analysis of transcripts using inductive reasoning and Dedoose software. 6 One reviewer assigned codes to each transcript (LCA or MDD), while a second verified the coding (JA or LZ); the group resolved discrepancies and revised code definitions as needed. Finally, all reviewers categorized codes into themes together. We identified representative quotes from each theme and organized themes into a visual schema. The study protocol complied with the Declaration of Helsinki, approved by the WashU Medicine Institutional Review Board (#202407201).
RESULTS
Overall participation and theory
We received survey responses from 17 of 123 PDs (13.8%) with a median of 4 (range 2–9) fellows per program, matching the national average of 4 fellows per program. Sample size varied by question, with 10 of 17 PDs completing all questions. We conducted two focus groups with FITs (six total participants) and three focus groups with PDs (eight total participants). All participating FITs were in their second year at six unique Accreditation Council for Graduate Medical Education (ACGME)–accredited fellowships, trained at programs sponsoring three FITs per clinical training year, and represented the Northeastern (4, 66.6%), Southern (1, 16.7%), and Midwestern (1, 16.7%) regions of the United States. PDs participating in focus groups oversaw ACGME‐accredited programs, training one to three FITs per clinical year in the Northeastern (4, 50%), Southern (2, 25%), Midwestern (1, 12.5%), and Western (1, 12.5%) regions of the United States. By comparison, the distribution of all United States adult rheumatology programs is 30% Northeastern, 35% Southern, 19% Midwestern, and 16% Western. Herein, we present survey data quantitatively and focus group findings descriptively.
Of the responding PDs, 7 of 17 (41%) indicated they did not have sufficient resources to create a comprehensive curriculum (Figure 1A). Limitations in faculty expertise (10 of 10, 100%) and time to lead sessions (8 of 10, 80%) were the top identified obstacles. All responding PDs (100%) used components of V‐FIT in their curricula, 100% (13 of 13) incorporating ViP‐Adult and 69% (9 of 13) integrating ViTLs.
Figure 1.
Rheumatology fellowship PD survey responses: factors influencing curriculum development and use of the ViP. ACR, American College of Rheumatology; PD, program director; ViP, Virtual Practicum for Adult Rheumatology.
Six themes from focus group transcripts describe the educational needs and preferences of adult FITs and PDs post COVID (Supplement 3). Our schematic diagram represents how these needs relate to one another (Figure 2). The core contains the educational content of V‐FIT (curricular topics) alongside board preparation materials (board review). This content optimally is delivered through sessions incorporating active learning (curriculum design) in ways that foster FIT interactivity (socialization). Unique factors related to virtual learning (virtual learning barriers) and V‐FIT implementation (administration and use) can influence the dissemination of V‐FIT resources to FITs, PDs, and their programs.
Figure 2.
Schematic diagram of curricular needs regarding V‐FIT programming. Curricular topics form the foundation of V‐FIT programming with requests to expand toward more advanced rheumatology topics and more board review. Curricular design that emphasizes active learning, encourages socialization, and upholds safe learning environments enhance V‐FIT educational materials. Scheduling and psychological insecurity impede learning during V‐FIT programming, and easily accessible V‐FIT materials can enhance use. V‐FIT, Virtual Program for Fellows‐in‐Training.
Curricular topics
FITs and PDs acknowledged that a large amount of foundational content exists in archived V‐FIT sessions on the ACR website, and 25% (3 of 12) of PD survey responders identified duplication of existing curricular content as a barrier to V‐FIT use (Figure 1B). Instead, FITs and PDs requested advanced topics that cover rarer rheumatic diseases, landmark trials, musculoskeletal radiology, and content experts’ opinions to deepen content beyond foundational concepts. These requests often overlapped with areas in which programs benefited from additional resource support because diagnoses were less common in their patient population or they lacked access to faculty expertise.
Board resources
Most PDs (11 of 13, 85%) reported incorporating previously published ACR Continuing Assessment Review Evaluation (CARE) questions into their programs’ curricula. FITs and PDs lamented the retirement of CARE questions in 2022, referencing the paucity of multiple‐choice questions for board preparation. They requested V‐FIT meet this shortfall through writing and sharing board‐style multiple‐choice questions or creating V‐FIT content that teaches FITs how to write questions, generating banks that could be shared across programs once vetted for accuracy.
Curriculum design
Focus group participants recognized that programs have variable access to resources needed to create curricula. PDs appreciated access to shared educational resources through V‐FIT; about half (6 of 13, 46%) of PD survey responders required at least one V‐FIT session as part of their curricula, and the majority (8 of 13, 62%) offered V‐FIT as an optional resource for fellows (Figure 1C). Five PDs (5 of 10, 50%) incorporated 16 or more V‐FIT sessions into their curricula annually. Some PDs also used V‐FIT as preparatory material for flipped classroom activities when FITs apply previously viewed V‐FIT content (4 of 13, 31%), as a supplement for struggling fellows (4 of 13, 31%) and as a surrogate curriculum for fellows on a leave of absence (2 of 13, 15%). PDs cited a lack of time to engage with V‐FIT themselves (2 of 12, 17%) and a lack of interactivity within sessions (3 of 12, 25%) as barriers to use. FITs echoed the predominance of lectures, requesting that future educational interventions engage FITs through learning activities, including cases, board‐style multiple‐choice questions, and discussions with content experts. Similarly, PDs expressed they were “very interested” in board preparation (11 of 13, 85%), lectures (10 of 13, 77%), and ask‐the‐expert sessions (8 of 13, 62%) in V‐FIT programming (Figure 3A).
Figure 3.
Rheumatology fellowship program director survey responses: preferences for future programming in the ViP. ACR, American College of Rheumatology; ViP, Virtual Practicum for Adult Rheumatology.
Socialization
FITs and PDs value social interaction that enhances learning. PDs indicated that opportunities for FITs to learn from content experts (12 of 13, 92%) and to engage with the ACR (10 of 13, 77%) would benefit V‐FIT (Figure 3B). FITs advised that social interaction during educational sessions must mitigate embarrassment associated with being incorrect publicly. They suggested elective participation and anonymous polling as instructional methods that would encourage engagement.
Virtual learning barriers
Focus group participants preferred short introductory sessions to enhance retention over the previous 60‐ to 75‐minute V‐FIT sessions. Regarding format, FITs suggested podcasts that could be accessed at their convenience. About three‐fourths of PDs (10 of 13, 77%) rated real‐time attendance of V‐FIT lectures as not at all or slightly important, echoing FITs’ preference for flexibility of virtual content delivery.
Administration and use
Implementation processes prevented FITs and PDs from using V‐FIT resources. PDs cited scheduling conflicts (challenges assigning time during FITs’ workhours, 7 of 12, 58%), fellows being too busy (FITs forgoing learning in favor of completing other tasks, 4 of 12, 33%), and difficulty accessing V‐FIT sessions on the ACR website (3 of 12, 25%) (Figure 1B) as frequent challenges. FITs agreed that their attention was divided among patient care, program conferences, and program didactics, impeding their engagement with V‐FIT. If real‐time attendance was required at future V‐FIT sessions, PDs identified the noon hour as the best time for FIT attendance. Additionally, FITs and PDs found it difficult to find V‐FIT materials on the ACR website and requested an easier mechanism for access.
DISCUSSION
In the COVID‐19 era, virtual curricula continued didactic instruction. Medical educators now are redefining virtual learning's role following the pandemic. 7 , 8 , 9 , 10 , 11 Our study demonstrates that adult rheumatology FITs and PDs continue to use virtual resources shared through V‐FIT. They especially value the archived interactive lectures for teaching FITs foundational content and for connecting with content experts, fellow trainees, and the ACR. Looking toward the future, FITs and PDs requested more content on advanced topics for senior fellows, more interactive and instructive design, increased ease accessing V‐FIT materials, and scheduling that matches FITs’ availability to attend real‐time sessions.
Notably, 41% of responding PDs reported insufficient resources to create a comprehensive rheumatology curriculum for their fellows. All PD survey respondents identified faculty expertise as an obstacle to curriculum development. In response, V‐FIT provides access to experts across rheumatology content domains. Educators who teach additional learners, including advanced practice providers, medical students, and residents, encounter similar limitations and may also benefit from V‐FIT. 12 This approach supports equity among programs, providing materials developed by content experts that map to the ACR Core Curriculum to all learners regardless of local resources.
Focus groups and survey responses frequently cited the need for board preparation materials. Board‐style multiple‐choice questions serve multiple purposes, simultaneously instructing trainees, assessing their skills, and preparing FITs for the experience of board examinations. 13 Other ACR programs may address board examination preparation, and V‐FIT programming can incorporate multiple‐choice questions to promote active learning while also supporting board preparation.
Virtual learning enhances convenience and access to clinical experts, but it challenges learner engagement. FITs expressed a preference for shorter sessions of 30 minutes or less. This reflects an overall trend to divide content into shorter segments that match learners’ attention spans. For example, an analysis of video lectures viewed on the edX online course platform found that learners’ median engagement time was only six minutes. 14 Shorter content additionally affords fellows the flexibility to incorporate materials as point‐of‐care references. Active learning methods, such as poll questions and interactive case discussions, also promote engagement. Both FITs and PDs proposed these methods; FITs added that making participation optional and anonymous would be important. To further refine the virtual learning environment, accessibility can improve by timing sessions at noon for each time zone as well as streamlining video storage in the learning management system. The working group proposed maintaining the V‐FIT library of lectures and, as topics need updating, creating content of shorter duration that better suits learning preferences and FITs’ busy schedules. Questions staged within sessions will help FITs consolidate presented information. Furthermore, a Meet‐the‐Professor‐style series, with each session scheduled at noon rotating through Eastern, Central, Mountain, and Pacific Standard time zones, will incorporate active learning and facilitate attendance for all FITs.
The Communities of Practice social learning theory proposes that a group of learners with a shared interest can enhance their learning through interactions with each other. 4 , 5 Correspondingly, initial surveys of V‐FIT participants in 2020 to 2021 highlighted V‐FIT's ability to foster connection within the rheumatology community during an isolating time. 3 In this study, adult FITs identified benefits to interacting with other fellows in V‐FIT sessions, particularly that interactions would make learning more engaging and allow them to gauge their own knowledge level. However, a need for fostering social connection among FITs was not a prominent theme for future V‐FIT programming, and survey respondents placed low importance on opportunities to connect with fellows from other programs. These findings may indicate that postpandemic, V‐FIT is valued for its content and interactive components insofar as they promote active learning and access to content experts more than socialization with peers.
This study was limited by its small sample size, which can affect the trustworthiness of our conclusions. The PD response rate was low, though not atypical for an online survey of physicians, 15 with 10% to 30% of PDs responding to previous surveys regarding V‐FIT. 3 The focus group sample size was also small and overrepresented the Northeastern geographic region. Nonetheless, focus groups reached thematic saturation, and triangulation of the survey and focus group data strengthen the trustworthiness of our results. Both surveys and focus groups were likely biased toward participants who had used V‐FIT more, thus underrepresenting barriers to its use. Participation of PDs and FITs who do not use V‐FIT may have disclosed additional opportunities to enhance curricula at well‐resourced programs and provided different suggestions for the future of V‐FIT. Iterative V‐FIT evaluations will verify the appropriateness of programmatic decisions and future directions.
Our study demonstrates ongoing demand from responding PDs and FITs for virtual rheumatology curricular content through V‐FIT. The program can build upon its archived content with future sessions that maximize active learning. Access to subspecialist expertise is highly valued, and V‐FIT can be leveraged to provide more uniform access to advanced topics among fellowship programs. In doing so, V‐FIT supports equitable education of all adult rheumatology FITs, preparing them to optimally deliver care to people with rheumatic diseases.
AUTHOR CONTRIBUTIONS
All authors contributed to at least one of the following manuscript preparation roles: conceptualization AND/OR methodology, software, investigation, formal analysis, data curation, visualization, and validation AND drafting or reviewing/editing the final draft. As corresponding author, Dr Zickuhr confirms that all authors have provided the final approval of the version to be published and takes responsibility for the affirmations regarding article submission (eg, not under consideration by another journal), the integrity of the data presented, and the statements regarding compliance with institutional review board/Declaration of Helsinki requirements.
Supporting information
Disclosure Form:
Data S1. Supplement 1: V‐FIT Needs Assessment Survey of Program Directors.
Data S2. Supplement 2: Focus Group Interview Guides.
Data S3. Supplement 3: Themes, Summaries, Associate Codes, and Illustrative Quotes from Focus Group Transcripts.
1Northwestern University Feinberg School of Medicine, Chicago, Illinois; 2Kansas City Physician Partners, Kansas City, Missouri; 3Duke University School of Medicine, Durham, North Carolina; 4American College of Rheumatology, Atlanta, Georgia; 5Hospital for Special Surgery and Weill Cornell Medicine, New York, New York; 6WashU Medicine, St. Louis, Missouri.
Drs Aizer and Zickuhr are co‐senior authors and contributed equally to this work.
Additional supplementary information cited in this article can be found online in the Supporting Information section (https://acrjournals.onlinelibrary.wiley.com/doi/10.1002/acr2.90097).
Author disclosures are available at https://onlinelibrary.wiley.com/doi/10.1002/acr2.90097.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Disclosure Form:
Data S1. Supplement 1: V‐FIT Needs Assessment Survey of Program Directors.
Data S2. Supplement 2: Focus Group Interview Guides.
Data S3. Supplement 3: Themes, Summaries, Associate Codes, and Illustrative Quotes from Focus Group Transcripts.