Arvin Damodaran

Hypermobility and sports injuries in junior netball players

Objective: To evaluate the incidence of hypermobility in young female netball players and to determine the relation between hypermobility, previous injuries sustained in netball or other sports, and the use of protective equipment. Methods: Under 16 year old female netball players from a local suburban netball association were assessed for joint hypermobility using the validated Beighton score (0–9, with higher scores indicating increasing hypermobility). Player profiles and details of sporting injuries, both netball and non-netball, and the use of protective equipment were gathered by means of a self completed questionnaire. Parental and child consent was obtained. Results: Two hundred netball players were recruited for the study. Twenty one percent of the subjects with a Beighton hypermobility score of 0–2 had sustained previous netball injuries compared with 37% with Beighton scores of 3–4, and 43% with scores of 5–9. These differences were significant (p<0.025). Injuries were most common in the ankle (42%), knee (27%), and fingers (15%). Thirty nine players (19%) wore protective equipment, and within this group 30 (77%) had sustained previous injuries. No association was detected between hypermobile joints and non-netball sporting injuries. Conclusions: In this study hypermobility was significantly associated with an increased prevalence of injuries in junior netball players. A targeted interventional approach may help to reduce injuries in this susceptible group.

The ABCs of entrustable professional activities: an overview of 'entrustable professional activities' in medical education.

Consultants regularly need to decide whether a trainee can be entrusted to perform a clinical activity independently. ‘Entrustable professional activities’ (EPA) provide a framework for justifying and better utilising supervisor entrustment decisions for trainee feedback and assessment in the workplace. Since being proposed by Olle ten Cate in 2005, EPA are emerging as an integral part of many international medical curricula, and are being considered by the Royal Australasian College of Physicians in the current review of physician training. EPA are defined as tasks or responsibilities that can be entrusted to a trainee once sufficient competence is reached to allow for unsupervised practice. An example might be to entrust a trainee to ‘Initiate and co‐ordinate care of the palliative patient’ with only off‐site or indirect supervision. Rather than attempting to measure directly each of the many separate competencies required to undertake such a complex task, EPA direct the trainee and supervisors attention to the trainees performance in a limited number of selected, representative, important day‐to‐day activities. EPA‐based assessment is gaining momentum, amongst significant concerns regarding feasibility of implementation. While the optimal process for designing and implementing EPA remains to be determined, it is an assessment strategy where the over‐arching goal of optimal patient care remains in clear sight. This review explores the central role of trust in medical training, the case for EPA and potential barriers to implementing EPA‐based assessment.

The ABCs of EPAs – an overview of ‘Entrustable Professional Activities’ in medical education

Consultants regularly need to decide whether a trainee can be entrusted to perform a clinical activity independently. ‘Entrustable professional activities’ (EPA) provide a framework for justifying and better utilising supervisor entrustment decisions for trainee feedback and assessment in the workplace. Since being proposed by Olle ten Cate in 2005, EPA are emerging as an integral part of many international medical curricula, and are being considered by the Royal Australasian College of Physicians in the current review of physician training. EPA are defined as tasks or responsibilities that can be entrusted to a trainee once sufficient competence is reached to allow for unsupervised practice. An example might be to entrust a trainee to ‘Initiate and co‐ordinate care of the palliative patient’ with only off‐site or indirect supervision. Rather than attempting to measure directly each of the many separate competencies required to undertake such a complex task, EPA direct the trainee and supervisors attention to the trainees performance in a limited number of selected, representative, important day‐to‐day activities. EPA‐based assessment is gaining momentum, amongst significant concerns regarding feasibility of implementation. While the optimal process for designing and implementing EPA remains to be determined, it is an assessment strategy where the over‐arching goal of optimal patient care remains in clear sight. This review explores the central role of trust in medical training, the case for EPA and potential barriers to implementing EPA‐based assessment.

Trust and risk: a model for medical education

Health care delivery, and therefore medical education, is an inherently risky business. Although control mechanisms, such as external audit and accreditation, are designed to manage risk in clinical settings, another approach is ‘trust’. The use of entrustable professional activities (EPAs) represents a deliberate way in which this is operationalised as a workplace‐based assessment. Once engaged with the concept, clinical teachers and medical educators may have further questions about trust.

‘Trust’ versus ‘competency’ in the workplace

Editor – ‘Would you trust them to look after your mother?’ is a favourite piece of shorthand amongst clinicians who are unofficially evaluating trainees for fitness to do the job. Although implicit, the concept of trust is clearly a foundation of the supervisor–trainee relationship. In this journal, Dijksterhuis et al. and Hauer et al. have empirically investigated the development of supervisor trust in trainees. As Gingerich suggests, trust may represent an alternative assessment framework, for which ‘entrustable professional activities’ may present an attractive method. So what makes the concept of trust seem so intuitive to clinical supervisors? Why might trust, from the clinical teacher’s perspective, provide a more meaningful taxonomy than competency in the workplace?

A Patient-Centered Approach to Developing Entrustable Professional Activities.

Purpose The medical education community is rapidly accepting the use of entrustable professional activities (EPAs) as a means of assessing residents. Stakeholder engagement is advised in developing EPAs, but no studies have investigated the role of patient input. In this qualitative study, the authors investigated what patient input may add to designing a patient-centered EPA. Method The authors chose “management of acute low back pain (LBP)” as a common, important clinical task on which to base the patient-centered EPA. In 2015, 14 patients who presented to a teaching hospital with acute LBP participated in semistructured interviews exploring their illness experience and expectations of doctors. Clinicians representing multiple disciplines participated in a focus group. The authors used the Framework Method to analyze data, identifying and developing themes, similarities, and differences between patient and clinician input. They used the findings to develop the EPA. Through an iterative procedure of data review and tracking data sources, they determined how patient and clinician input informed each EPA descriptor. Results Drawing from their firsthand experience of LBP, patients described unique expectations of trainees which directly informed EPA descriptors. For example, the authors primarily used patients’ detailed descriptions of desirable and observable trainee behaviors to inform the required attitudes descriptor. Conclusions Patients can provide unique contributions, complementary to those of clinicians, to EPAs. Consultations with patients led to the development of a patient-centered EPA, which aligned best clinical practice with patient expectations. Educators seeking to apply patient-centered care to EPA development could adopt a similar approach.

The experience of patients admitted to hospital with acute low back pain: a qualitative study

To understand the patient experience of being admitted to hospital with acute low back pain (LBP), with a view to developing suggestions for care and LBP management guidelines.

Time to say goodbye to learner-centredness?

1 World Federation for Medical Education. The Edinburgh Declaration. Med Educ 1988;22 (5):481–2. 2 Bandiera G, Kuper A, Mylopoulos M, Whitehead C, Ruetalo M, Kulasegaram K, Woods NN. Back from basics: integration of science and practice in medical education. Med Educ 2018;52 (1):78–85. 3 Berkhout JJ, Helmich E, Teunissen PW, van der Vleuten CPM, Jaarsma ADC. Context matters when striving to promote active and lifelong learning in medical education. Med Educ 2018;52 (1):34–44. 4 Irby DM, O’Sullivan PS. Developing and rewarding teachers as educators and scholars: remarkable progress and daunting challenges. Med Educ 2018;52 (1):58–67. 5 Sitzmann T, Ely K. A meta-analysis of self-regulated learning in workrelated training and educational attainment: what we know and where we need to go. Psychol Bull 2011;137:421–42. 6 Dotters-Katz S, Hargett CW, Zaas AK, Criscione-Schreiber LG. What motivates residents to teach? The Attitudes in Clinical Teaching study. Med Educ 2016;50 (7):768–77. 7 Williams RG, Klamen DL. See one, do one, teach one–exploring the core teaching beliefs of medical school faculty. Med Teach 2006;28:418–24.accepted for publication 13 September 2017

Cut-scores revisited: feasibility of a new method for group standard setting

BackgroundStandard setting is one of the most contentious topics in educational measurement. Commonly-used methods all have well reported limitations. To date, there is not conclusive evidence suggesting which standard setting method yields the highest validity.MethodsThe method described and piloted in this study asked expert judges to estimate the scores on a real MCQ examination that they consider indicated a clear pass, clear fail, and pass mark for the examination as a whole. The mean and SD of the judges responses to these estimates, Z scores and confidence intervals were used to derive the cut-score and the confidence in it.ResultsIn this example the new method’s cut-score was higher than the judges’ estimate. The method also yielded estimates of statistical error which determine the range of the acceptable cut-score and the estimated level of confidence one may have in the accuracy of that cut-score.ConclusionsThis new standard-setting method offers some advances, and possibly advantages, in that the decisions being asked of judges are based on firmer constructs, and it takes into account variation among judges.

Enhancing the defensibility of examiners’ marks in high stake OSCEs

BackgroundMost assessments in health professions education consist of knowledge-based examinations as well as practical and clinical examinations. Among the most challenging aspects of clinical assessments is decision making related to borderline grades assigned by examiners. Borderline grades are commonly used by examiners when they do not have sufficient information to make clear pass/fail decisions. The interpretation of these borderline grades is rarely discussed in the literature. This study reports the application of the Objective Borderline Method (version 2, henceforth: OBM2) to a high stakes Objective Structured Clinical Examination undertaken at the end of the final year of a Medicine program in Australia.MethodsThe OBM2 uses all examination data to reclassify borderline grades as either pass or fail. Factor analysis was used to estimate the suitability of data for application of OBM2. Student’s t-tests, utilising bootstrapping, were used to compare the OBM2 with ‘traditional’ results. Interclass correlations were used to estimate the association between the grade reclassification and all other grades in this examination.ResultsThe correlations between scores for each station and pass/fail outcomes increased significantly after the mark reclassification, yet the reclassification did not significantly impact on students’ total scores. Examiners, students and program leaders expressed high levels of satisfaction and the Faculty’s Curriculum Development Committee has decided that the OBM2 will be used for all future clinical examinations. Implications of the OBM2 are discussed.ConclusionsThe OBM2 provides a feasible, defensible and acceptable solution for classification of borderline grades as either pass or fail.