The time has come to incorporate more teaching and formalized assessment of skills in synovial fluid analysis into rheumatology training programs

Abstract

Arthrocentesis with synovial fluid analysis can directly dictate the diagnosis and management of previously unexplained joint effusions (1). In addition to its obvious value in confirming the diagnosis of crystal-induced arthritis, fluid analysis can help differentiate among other causes of polyarthritis. This is now particularly relevant, given the potential of overdiagnosing rheumatoid arthritis (RA) using the newer diagnostic algorithms that seem to emphasize sensitivity over specificity (2–4) in order to appropriately encourage the early aggressive therapy of RA. We previously analyzed the accuracy of diagnosis in a series of patients using the 1987 American College of Rheumatology (ACR) criteria for the classification of RA, and noted that the diagnostic specificity could be improved by including synovial fluid analysis (5). In our analysis, 19 of 157 patients diagnosed with RA would have been alternatively classified if synovial fluid findings had been utilized in the diagnostic process. Yet, the 2010 ACR/European League Against Rheumatism classification criteria for the early diagnosis of RA (6), a major international effort that notes the need to exclude other causes of synovitis, do not recognize the diagnostic value of joint aspiration with synovial fluid analysis. We believe that an underemphasis on synovial fluid analysis in clinical training has contributed to an underutilization of the test in clinical practice and an underemphasis in academic writings and practice guidelines. Microscopic examination of synovial fluid for crystals remains the gold standard for the diagnosis of gout and clinically relevant calcium pyrophosphate deposition disease (7–10). Synovial fluid analysis can alter the clinical diagnosis (1,11). Although the concern regarding the inconsistent quality of fluid examination is well-founded (12–15), this can be rectified at least for rheumatologists with appropriate training and a requirement for the demonstration of competency prior to certification. Synovial fluid analysis has been a valuable component of rheumatologic practice for a half-century. It is a skill that is expected by the Accreditation Council for Graduate Medical Education (ACGME) to be learned during rheumatologic training. Yet, only some fellowship programs have well-defined performance measures to assess the skills of their graduating fellows, and synovial fluid analysis is not rigorously assessed on the rheumatology certification examination. An informal survey of program directors and direct observation of our own and other programs indicate that many programs do not explicitly define “competency” to perform synovial fluid analysis. No consensus has been reached on a standardized method for training and evaluating fellows (and staff) in the performance of fluid analysis, nor have outcomes of various utilized teaching approaches been fully evaluated. A number of challenges exist in trying to incorporate a rigorous synovial fluid analysis module into fellowship training (including the lack of experienced mentors in some programs), particularly if it is desired to have uniformity between programs and a shared definition of competency. However, we believe that these challenges can be systematically overcome if the resolve is present. Several educational programs to teach synovial fluid analysis and assess the skills of trainees have been described. For example, we distributed short multiple-choice quizzes on synovial fluid analysis at ACR workshops, but the validity of the quiz and the lasting educational value of the workshop have not been rigorously assessed. A similar quiz (available at http://www.med.upenn.edu/synovium/ sfanalysis.shtml) was developed at the University of Pennsylvania. The questions were designed to assess not only H. Ralph Schumacher, MD: University of Pennsylvania and Philadelphia VA Medical Center, Philadelphia; Lan X. Chen, MD, PhD: Penn Presbyterian Medical Center, Philadelphia, Pennsylvania; Brian F. Mandell, MD, PhD: Cleveland Clinic Foundation, Cleveland, Ohio. Dr. Mandell has received consultant fees, speaking fees, and/or honoraria (less than $10,000 each) from Novartis, Pfizer, and Savient. Address correspondence to Brian F. Mandell, MD, PhD, Cleveland Clinic, A50, 9500 Euclid Avenue, Cleveland, OH 44195. E-mail: mandelb@ccf.org. Submitted for publication February 22, 2012; accepted in revised form April 12, 2012. Arthritis Care & Research Vol. 64, No. 9, September 2012, pp 1271–1273 DOI 10.1002/acr.21714 © 2012, American College of Rheumatology