Arthritis Care & Research Vol. 63, No. 1, January 2011, pp 58 – 64 DOI 10.1002/acr.20329 © 2011, American College of Rheumatology
SPECIAL ARTICLE: QUALITY OF CARE IN THE RHEUMATIC DISEASES
Ensuring Quality of Care Through Implementation of a Competency-Based Musculoskeletal Education Framework MELLICK J. CHEHADE, TERESA A. BURGESS,
AND
Introduction As the Bone and Joint Decade 2000 –2010 draws to a close, it is timely to review its impact on musculoskeletal medical education, which was clearly identified by the World Health Organization as a key factor contributing to less than optimal musculoskeletal care (1). The increasing burden of musculoskeletal disorders (including chronic bone and arthritic conditions) and the uncertain quality of care provided (2,3) has meant that there is a growing imperative to ensure that optimal, evidence-based, and cost-effective treatment is being provided to people with musculoskeletal disorders by medical practitioners (4). In 2004, the Bone and Joint Decade established the International Education Task Force and Undergraduate Curriculum Development Group to develop strategies to address the issue of insufficient and/or inadequate medical education, particularly in the areas of basic and clinical science (5,6). They released global core recommendations for a musculoskeletal undergraduate medical curriculum, which were designed to enable the development of a locally applicable musculoskeletal curriculum that was able to meet national guidelines and be reflective of local needs, priorities, and opportunities (5). Despite the release of the global core recommendations for a musculoskeletal undergraduate medical curriculum, in 2007 Woolfe and Åkesson identified that the poor quality of medical education and a lack of coordination between the different disciplines and professional specialties working in musculoskeletal health care have meant that people do not receive the best practice treatment (6). Mellick J. Chehade, PhD, MBBS, FRACS, FAOrthA, Teresa A. Burgess, MPHC, Grad Dip Nursing Management, RN, David J. Bentley, PhD: University of Adelaide, Adelaide, South Australia, Australia. Dr. Chehade has received consultant fees (less than $10,000) from the Australian government. Address correspondence to Mellick J. Chehade, PhD, MBBS, FRACS, FAOrthA, Discipline of Orthopaedics and Trauma, Faculty of Health Sciences, University of Adelaide, Adelaide, South Australia 5005, Australia. E-mail: mellick.
[email protected]. Submitted for publication April 9, 2010; accepted in revised form August 12, 2010.
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Furthermore, in 2007 Day et al demonstrated significant deficiencies in the knowledge of chronic arthritic conditions in graduating medical students (2). Deficiencies in undergraduate education in musculoskeletal science have also been identified by medical students and graduates in studies conducted in a number of countries (2,7–10), and there is an obvious requirement for clinically relevant, evidence-based curriculum design that integrates traditional scientific and clinical disciplines. The Australian Musculoskeletal Education Collaboration (AMSEC) project began in Australia in 2005, with the aim of developing nationally agreed musculoskeletal core competencies (based on the Bone and Joint Decade curriculum recommendations) for implementation in all Australian medical schools. Initiated by the Australian Orthopaedic Association and funded by the Australian government, this project has succeeded in bringing together all key musculoskeletal specialist and representative organizations in a national, multidisciplinary education collaboration (including orthopedics, rheumatology, general practice, rehabilitation medicine, sports medicine, endocrinology, neurology, geriatrics, radiology, pediatrics, nursing, and interested allied health professions). While the Bone and Joint Decade recommendations formed the base from which the Australian competencies were developed, it was also vital that specific Australian standards and requirements were considered. The AMSEC competencies were therefore also related directly to the Australian Medical Council standards and principles and The National Patient Safety Framework (11,12). The purpose of this article is to outline the relevance of a competency-based approach to musculoskeletal education and to describe the development of the AMSEC musculoskeletal core competencies. Furthermore, we demonstrate the significance of the AMSEC competencies and the competency education process for optimal education in musculoskeletal medicine relative to chronic rheumatic disease.
Competency-based medical education In order to ensure an effective integration of musculoskeletal competencies into medical curricula, it is important to understand the broader context of competency-based medical education and the issues surrounding it. Competency
Using a Musculoskeletal Education Framework to Ensure Quality in medical education can be defined as encompassing a theoretical foundation of scientific knowledge that links task competency to professional standards of communication, evidence-based practice, and social competency (13). Traditionally, the focus of competency-based education has been on the performance of defined learning outcomes reflective of vocational roles. Competency-based education originated from a need to improve the capability of the general national workforce. Progression in a competencybased model is not defined by time spent, but rather the competency achieved in a given task, which is defined by the vocational skill set required (14). In medical education, however, competency-based education requires a much broader view of competency-based training, as current definitions largely do not consider the complex nature of clinical practice and ignore the important vocational link between the task and the meaning of the task in different situations (13,15). The CanMEDS 2005 Physician Competency Framework and the General Medical Council’s Tomorrow’s Doctors provide specific competency-based guidelines for medical training that encompass this broader view (16,17); however, they are general rather than specific documents aimed at identifying outcomes and standards for medical education rather than specifics to guide curriculum development. A competent doctor is one who can not only perform a task but also, based on appropriate supporting knowledge of evidence and options, decide if the procedure should be performed, how it should be performed, and when it should most appropriately be performed. Therefore, a framework for competency-based medical education must encompass aspects that are reflective of judgment and wisdom in clinical practice, and this requires a much broader vision than merely describing a set of procedural skills. Graduating medical students must be able to demonstrate the ability to apply a
59 broad knowledge base related to a task as well as the task itself to successfully deal with a variety of clinical scenarios (18). Doctors need to be applied scientists with a sound understanding and background in the application of contemporary medical research and knowledge of the technologies and limitations associated with that research. This higher level of competency works on the premise that, as well as having the practical skills to undertake medical procedures, the competent doctor is also a knowledgeable, analytical scientist and a caring professional that displays good judgment and wisdom in practice. The inclusion of core principles associated with the basic sciences of anatomy, physiology, and biochemistry that underlie higher-level thinking and their subsequent application to clinically-based problems that are common in medical practice is therefore a clear imperative for medical education (19,20). Science is evolving rapidly and changes in medical management are directly linked to advances in science, which means that effective medical practitioners must have a firm grasp of these contemporary sciences. While it is acknowledged that most medical schools already provide students with material related to the basic sciences, this is generally not well defined nor specifically linked to clinical competency, and the need to optimize and refine the training of student doctors in line with these suggestions is of considerable importance. A competency-based musculoskeletal framework for medical education must acknowledge that it will be implemented into a variety of existing medical curricula; it is not a standalone curriculum of itself. Indeed, it is of key importance that medical schools maintain their own identity, philosophy, and focus in regard to the delivery of medical education. The diversity of medical curricula, and the need to identify and respond to local issues as well as national issues (such as the widespread prevalence and
Figure 1. An overview of the Australian Musculoskeletal Education Collaboration (AMSEC) framework. MSK ⫽ musculoskeletal.
60 severity of osteoarthritis and osteoporosis), is vital for medical curricula to remain valid and functional. A rigorous competency-based framework for musculoskeletal education allows a wide variety of medical curricula to map their contents against the recommended competencies and integrate elements of the framework as required.
The AMSEC framework and competencies The AMSEC project has established a minimum national baseline reference for musculoskeletal education in Australian medical schools through the development of evidence-informed, principles-based core competencies, developed using a national consensus process. A series of nationally-based, interdisciplinary, and interprofessional expert working groups were established to review draft competencies, which were initially developed by the AMSEC project team, in the areas of physical examination, musculoskeletal emergency conditions, patient education and self-management, procedural skills, and rehabilitation. In addition, basic and clinical science working groups were established to review a basic and clinical science supporting knowledge foundation acting as an appropriate context for the competencies. The working groups were established by way of invitation to a field of
Chehade et al experts in all areas of musculoskeletal care and management, as well as medical education more generally. A needs assessment was not required, as the Bone and Joint Decade recommendations and accompanying literature on musculoskeletal education deficiencies were used as a starting platform, together with a broad consultation process undertaken with all Australian medical schools (21). In addition to the working groups, experts from across Australia specific to each of the areas dealt with by the working groups were brought together to review the draft framework and competencies and refine them further. Basic and clinical science knowledge was always envisaged as forming a core component of the AMSEC competencies. To achieve this, a simple, lucid, and practical framework for organizing and presenting this core knowledge was specifically developed to support the competencies. The AMSEC framework therefore encompasses a body of comprehensive basic and clinical science knowledge forming the foundation for, and directly linking to, clinically-based competencies. This framework allows a common foundation for learning, with more focused and/or specialized areas building on a general foundation. The clinical relevance of this underpinning basic science allows the medical student to better understand and en-
Figure 2. The Australian Musculoskeletal Education Collaboration core competencies: biomechanics. MSK ⫽ musculoskeletal.
Using a Musculoskeletal Education Framework to Ensure Quality visage the longer-term “roadmap” of their medical education. The competencies are also designed with a focus on individualized patient care while taking into consideration and appropriately weighing population issues. A web-based process was developed, allowing working group members to comment and provide feedback on any aspect of the competencies. Once the first draft of the AMSEC framework and competencies was developed, they were uploaded to a password-protected web site, where the expert working groups were invited to review and comment on them and comments made could be seen by all members of their working group. Once the initial consultation period was completed, the AMSEC project team considered all comments, revised the competencies accordingly, and then uploaded the revisions for final approval. It is important to stress that the AMSEC framework is not a curriculum. It was designed to define a reference point of musculoskeletal education appropriate for Australian universities and to provide suitable learning outcomes. The defined competencies are highlighted, with the supporting core knowledge, skills, and attitudes defined and detailed to be consistent with the required competency level. The level of detail of the AMSEC competencies enables them to be mapped into existing curricula, facilitating the identification of important gaps that may need to be addressed. The content addresses current expected practice levels while allowing for important expected and emerging changes to practice. The basic science knowledge foundation articulated in the AMSEC framework encompasses key principles beginning at the cellular/molecular level, which is then related to knowledge of the more specialized structural details,
61 including the normal form and function of musculoskeletal tissues (including anatomy and physiology) and the processes resulting in abnormal reactions, including chronic bone and joint-related pathology. A particular focus on anatomy has been identified as vital to the broader understanding required in musculoskeletal medicine, and this is reflected in the greater detail provided. Great care has been taken to ensure that the anatomy covers important general principles relevant to the level of understanding and practice required of an undifferentiated intern more likely to progress to general/family practice rather than a musculoskeletal surgical specialty (22). It is therefore more specifically geared to the interpretation of history/physical examination findings and basic imaging plus the performance of some common minor surgical and injection procedures. Building on the basic science principles and objectives, the clinical science competencies identified in the AMSEC framework define general principles and encompass not only the directly practical aspects of assessment and management of musculoskeletal conditions, but also other important related management modalities and issues. These include patient education and self-management, prevention, evidence appraisal and critical reasoning, safety and quality care, professionalism, and other areas required for the provision of quality patient-focused holistic care. For this reason, many of the clinical competencies that are the foundation of or common across disciplines have been separated from those that would be considered more specifically musculoskeletal. The structure of the AMSEC framework has allowed efficient linking of specific competencies to nationally agreed, evidence-based guidelines in areas such as osteoporosis and arthritis (23,24), thus incorporating both management and patient education as-
Figure 3. Example of an Australian Musculoskeletal Education Collaboration learning objective. MSK ⫽ musculoskeletal.
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Figure 4. Australian Musculoskeletal Education Collaboration “knowledge levels of practice.” MSK ⫽ musculoskeletal.
pects of musculoskeletal care. Specific guidelines are also linked to competencies, providing up to date educational resources. The AMSEC framework and an example of a musculoskeletal competency are shown in Figures 1 and 2. Each element of the framework has defined learning outcomes that become more specific and detailed as the framework “unfolds,” thereby facilitating the spiraling of knowledge and the identification of content more appropriately required for future specialist training. The competencies are horizontally and vertically integrated in a “roadmap” of clearly defined learning outcomes that are assigned to each element of the framework and link to postgraduate and specialist training competencies, thus facilitating “streaming” or early planning for post–medical school education (Figure 3). In order to develop this “roadmap,” a system of identifying “levels of practice” for both knowledge and procedural skills has been developed. These have been based on review of a number of specialist curricula and levels defined by Bandaranayake (25) (Figures 4 and 5). The Royal Australian College of General Practitioners has adopted AMSEC competencies as an appropriate, assumed medical school exit standard prior to prevocational training on which further training can be
planned and structured as a part of musculoskeletal training for general practice. Although the AMSEC framework and competencies are not yet endorsed standards, they are firmly based on evidenced-based guidelines (and consensus statements where guidelines are absent). AMSEC is in the process of requesting endorsement in conjunction with mapping of the material within medical and allied medical curricula. A key strategy has been the inclusion of professional colleges in the Project Steering Committee and expert working groups, with a view to future endorsement of the competencies as standards. In order to facilitate the uptake of the AMSEC framework and competencies, a series of evidence-based resources is also being developed. These include standardized physical examination videos with accompanying information and supporting evidence, multimedia presentations, podcasts, and formative assessment tools. The framework itself has been designed to be flexible and adaptable in order to support evolving competencies, which are expected to change with the ever-increasing evidence base for musculoskeletal conditions. This includes the recognition of the current and evolving burden
Figure 5. Australian Musculoskeletal Education Collaboration “procedural skills levels of practice.”
Using a Musculoskeletal Education Framework to Ensure Quality and priorities of musculoskeletal conditions in the Australian community and the scientific developments to facilitate their assessment and management. The scope of the AMSEC framework also encompasses broader issues of patient education, both directly and through improved doctor–patient education. With the chronic nature of many musculoskeletal conditions and the influence of lifestyle choices, there is an increasing need to develop and direct patients toward self-management strategies. A key element of the AMSEC framework is the ability to use both the framework and competencies in an interdisciplinary context. Other musculoskeletal-related professions such as physiotherapy have been involved in the development and review of the AMSEC program, and there are currently discussions with physiotherapy and exercise physiology professional bodies regarding the use of the AMSEC framework to provide consensus on core knowledge required in these allied professionals dealing with musculoskeletal conditions. A horizontal integration of multidisciplinary education such as this would ensure that all Australian health care professionals are suitably equipped with clinically relevant knowledge and competency to address the increasing impact of musculoskeletal conditions such as osteoarthritis and osteoporosis in Australia. The AMSEC project does not underestimate the many challenges in implementing an interdisciplinary education framework, including the development of processes to assess levels of competency. However, if the concept of competence is clearly defined, the competencies themselves agreed upon, and the levels of competence allocated, then the challenge of assessment becomes less daunting. Although a debate about valid assessment of competency is not within the scope of this article, it is broadly suggested that an assessment of competency should consider interpretation and analysis and provide a valid evaluation of professional attributes and communication skills, rather than being a narrow evaluation of isolated knowledge or manual skills. A key outcome for the AMSEC project has been to facilitate the reengagement of clinician teachers who often feel frustrated by both a lack of direction with respect to their teaching objectives and inadequately prepared students with respect to core anatomic and basic science knowledge. The task of the educating clinician is greatly facilitated when the specific teaching outcomes are clearly defined and known by both teacher and student, and the necessary supporting basic and clinical science knowledge requirements have been addressed prior to clinical teaching encounters. A number of strategies have been developed to promote this outcome, consisting of the inclusion of clinicians in all stages of framework and competency development, a focus on the practical clinical application of basic and clinical science theory, and the development of specific and detailed learning objectives and linked resources that can be accessed by all students and teachers, thus providing a roadmap of required learning across the entire medical education curriculum.
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Discussion Implementation of the AMSEC framework and competencies began in early 2010 with identified curriculum developers in conjunction with medical deans in the majority of Australian medical schools. This process is ongoing and has broadly involved “mapping” the AMSEC material with existing curriculum. The use of workshops comprising nominated educators, relevant academics, and curriculum developers will facilitate this process at a local, university level. Ongoing research proposes the quantification of the processes involved in mapping the competencies within a medical degree program, and a comprehensive evaluation process is planned to track the initial impact of the AMSEC material on student learning using multimedia resources. With the competency review process designed to remain active, this will ensure ongoing relevance of the standards and allow the early identification of important changes required, resulting in a significant reduction in the lag time for the translation of changing clinical requirements and associated evidence-informed practice into effective education strategies. By design, both interdisciplinary education and collaboration should also be enhanced and further efficiencies gained through the joint development and sharing of educational resources and facilitating the reengagement of clinician teachers. The Bone and Joint Decade 2000 –2010 provided the international stimulus for a number of countries to address the issue of musculoskeletal medical education, based on the global core recommendations for a musculoskeletal undergraduate medical curriculum. In Australia, the overall aim of the AMSEC project is to improve the healthrelated outcomes for Australians with musculoskeletal conditions by improving the quality and efficiency of health care through raising the standard of musculoskeletal education provided to undergraduate health care students and linking this to postgraduate and general practice training. The development of the AMSEC framework and competencies has greatly facilitated the process of defining the knowledge, skill, and attitude base for the competencies, as well as allowing a more efficient mapping of the education requirements into existing curricula. AUTHOR CONTRIBUTIONS All authors were involved in drafting the article or revising it critically for important intellectual content, and all authors approved the final version to be submitted for publication. Dr. Chehade had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study conception and design. Chehade, Burgess, Bentley. Acquisition of data. Chehade, Burgess, Bentley. Analysis and interpretation of data. Chehade, Burgess, Bentley.
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