Many different approaches have been used to define core curricula - ranging from the opinions of one individual or group of experts, literature review and synthesis, opinion surveys, job analysis, and various other qualitative and quantitative research methods (Harden 1986). For the current study, it was agreed that a sequential approach combining expert group opinion, review and synthesis of existing literature and curricula, followed by a stakeholder survey to consider and rate a draft competency framework, would be most appropriate. Because of the diversity of backgrounds and areas of specialist activity within the ESSKA community, a single framework of core competencies with a modular design was chosen, so that individual members could easily identify the core competencies relevant to their own areas of practice and interest. It was decided that each competency would be defined in terms of the clinical condition or situation and the relevant procedure to manage this, and that further exploration of how and when individuals should achieve these would be deferred for future research. Groups of experts would be selected to research, develop and refine each of the specialist areas of the core curriculum, recognising that it was unlikely that any one individual would have sufficient expertise in all of the specialist areas covered by ESSKA. Managerial approval for the project was secured from the ESSKA Board, who confirmed that no additional ethical approval was required.
Expert group selection and drafting of curricular modules
The Core Curriculum Working Group was initially constituted of seven expert groups, reflecting the seven main areas of activity within ESSKA, led by the ESSKA Education Secretary (ML) with assistance from a medical educationalist (MR). Each expert group had a nominated member of the ESSKA Board, plus two nominated specialists from each of the following ESSKA Sections and Committees: Knee Arthroscopy (via the Arthroscopy Committee); Degenerative Knee (via the European Knee Association); Hip (via the Hip Committee); Sports Medicine (via the European Sports Medicine Association); Shoulder (via the European Shoulder Association); Foot and Ankle (via the Ankle & Foot Associates Section); and Elbow and Wrist (via the Elbow & Wrist Committee). Many of the expert groups recruited additional members based on their specialist skills and experience. Each expert group worked semi-independently in liaison with the educationalist to review the literature and relevant existing national and international curricula, including the content of existing and forthcoming ESSKA courses and training materials. They also liaised with colleagues and their associated Sections and Committees, and iteratively develop and agree an initial draft of core competencies for their own specialist area. Some documents were found to be relevant to multiple specialist areas and so were shared between them, such as the 2015 EFORT and 2000 AOSSM curricula [13,14,15], and various national curricula for orthopaedic trainees in Europe and elsewhere. In reviewing and drawing from such curricula, the expert groups were mindful to focus on developing a set of core competencies at an appropriate level for ESSKA members who have completed their specialist training and not, for example, another comprehensive curriculum for orthopaedic or sports medicine trainees.
Reviewing and synthesizing curricula from each specialist area
After sharing earlier drafts and multiple online meetings, the Working Group met in person to review, discuss and refine the early draft curricula from each of the seven expert groups. Areas of overlap were discussed, there was some movement of competencies between groups, and consensus was reached on formatting issues, nomenclature, scope, level of detail, a common structure and sequence for the curriculum, along with the next steps for refining the drafts and creating a single online stakeholder survey in English. The Working Group agreed to the Elbow & Wrist group’s proposal to focus more specifically on ‘Elbow & Forearm’; that the arthroscopic and degenerative knee groups would combine their efforts and draft curricula and become a single ‘Knee’ group; and that preventive and non-surgical procedures for all anatomical areas would be incorporated by the Sports Medicine group into a single set of ‘Sports & Exercise’ competencies. The resulting six expert groups then continued to work on their own areas of the core curriculum, incorporating the feedback and principles agreed by the Working Group, in liaison with their associated Sections and Committees, until satisfied that their draft list of competencies was ready for wider dissemination and feedback.
Online survey creation and pilot
A draft online survey was created in SurveyMonkey (www.surveymonkey.com), with the agreed competencies from each of the six expert groups, in the agreed sequence of Sports & Exercise followed by each anatomical area from Shoulder down. Consistent with the aims of the current research, the Working Group prioritised the perceived importance of each competency for ESSKA members, rather than exploring when or to what extent these should be achieved using a variation of Miller’s triangle (Miller 1990). Respondents were therefore initially asked to rate the importance of each competency (defined by the type of condition as a stem question followed by a series of specific procedures) on a 3-point Likert scale, whether they felt there was anything missing or unclear, and some demographic information. Respondents were also asked at what level of training course they would expect to see the competency covered, to guide future educational activities, but these did not inform development of the core competencies and so these questions and data are not reported here. The survey was then reviewed and piloted twice by members of the Working Group and others, who felt that the 3-point Likert scale was not sufficiently discriminatory, that the whole survey was lengthy, and some specialist areas were less relevant to certain individuals. It was therefore decided that stakeholders would be asked to rate the importance of each competency for ESSKA specialists on a 5-point Likert scale (1 = Not Important; 2 = Limited Importance; 3 = Important; 4 = Very Important; 5 = Essential) - both in their own main specialist area and as many of the other areas as they felt able to rate. Additionally, some duplication and overlap between specialist areas was removed – for example, steroid injection for frozen shoulder was removed from Shoulder as it was already covered by ‘Injection therapy’ in Sports & Exercise. There was also some resulting refinement and standardisation of terminology, such as changing ‘upper’ to the more anatomically-correct term, ‘proximal’. The Working Group then agreed a final list of 285 competencies (detailed in Table 2) for inclusion in the online stakeholder survey, with 42 in Sports & Exercise; 67 in Shoulder; 34 in Elbow & Forearm; 41 in Hip; 56 in Knee (combined arthroscopic and degenerative); and 45 in Foot & Ankle.
Stakeholder survey recruitment and information
An initial e-mail invitation to complete the online survey was sent to all 2954 ESSKA members, as well as 5814 ‘friends of ESSKA’ (former ESSKA members and participants in ESSKA congress, courses or fellowships). Two further reminders were sent to the whole membership, and some people were also directly encouraged to respond by colleagues in the Board or Working Group. Participants were informed about the research including how the draft competencies had been developed, the scope of the curriculum and clarification that it did not include all aspects of an orthopaedic training curriculum nor new and experimental procedures, and ethical issues such as consent and respondent anonymity. It was also made clear that all competencies implicitly assume the specialist has adequate facilities, resources and staff support to undertake the procedure and manage common complications (such as minor post-op infection and bleeding), as well as sufficient prerequisite training both generally (e.g. communication and infection control) and specifically for that procedure (including being able to appropriately assess the patient, select the most appropriate procedure, and have the knowledge and expertise to perform the full procedure safely and successfully). participants were then asked to respond to all questions related to their own specialist area and as many of the other areas as they felt able to rate, as well as some demographic questions. Figure 1 shows a typical screenshot from the online survey.
Analysis of findings and expert group decisions
After sufficient responses had been collected, the survey was closed and the data were exported, sorted and provisionally analysed in Excel. Responses which did not contain meaningful data were removed, and the ratings were analysed in various ways, including calculating the Mean rating of all responses for each competency, the Mean rating for the subgroup of respondents who specialised in that particular area, and the percentage of all respondents who indicated each competency should be Essential or Very Important. Demographic data were also summarised, and all free-text responses were collated in a single document for analysis. A teleconference was then arranged for each of the six expert groups with the Educationalist to review and make some collective decisions related to the survey findings in each of their specialist areas. First, with the competencies ranked by Mean of all responses, the expert groups were asked to consider how many Likert scale ‘Levels’ these represented, and whether any of the lowest-rated Mean competencies should be removed from the draft list. Second, the expert groups were asked to select an appropriate cut-off between each Level, with the competencies ranked by the percentage of respondents indicating it should be higher than this (i.e. the percentage who rated competencies as 5 for the cut-off below ‘Essential’, and as either 4 or 5 for the cut-off below ‘Very Important’). Third, each expert group also reviewed all the free-text comments to determine whether any competencies should be added or reworded.