Abstract
Background
Sports Medicine is an upcoming postgraduate speciality in India. A MD Sports Medicine specialist is expected to contribute in the prevention of sports injuries, sportsmen training and enhancement of performance apart from being involved in planning of conduct of sports events amongst many other roles and responsibilities. This requires hands-on training and acquisition of skill sets required to perform these roles. The National Medical Council of India highlights the need for a competency based curriculum and has laid down guidelines for the course. There was a felt need to develop Entrustable Professional Activities (EPAs) and milestones based on the prescribed curricula and develop a portfolio for continuous monitoring of the achievement of these EPAs.
Methods
A five step model was done by experts in the field to prepare the EPAs, milestones and portfolio. This consisted of faculty development, identification of the EPAs and milestones and portfolio preparation.
Results
114 EPAs and 961 milestones were identified by the subject experts. The portfolio was developed with the help of specialists and faculty of the field of sports medicine, and medical educationists.
Conclusion
Post graduate medical education is mandated to be competency based. A portfolio has been developed in the current exercise for use in a competency based post-graduate curriculum in sports medicine. This will help in the better implementation of CBME in the country.
Keywords: Entrustable professional activities, Milestones, Sports medicine, Portfolio, Competency based medical education
Introduction
MD Sports medicine in India is not even a decade old. The speciality is presently in the blooming phase and recently has gained traction to be offered in many colleges across the country. A sports medicine specialist is expected to contribute in the prevention of sports injuries, sportsmen training and enhancement of performance apart from being involved in planning of conduct of sports events amongst many other roles and responsibilities. This requires hands-on training and acquisition of skills to perform these roles. The curriculum guidelines are laid out by the National Medical Commission in India and different universities where the college is affiliated.1 Sports Medicine is a relatively new field and there is a need to groom the students as per the competencies required of them in this speciality and not to an already existing speciality like orthopaedics or Physical Medicine and Rehabilitation. This has also been highlighted on an international platform.2,3 Ensuring standardisation in sports medicine postgraduate training is vital for ensuring their ability to perform the role of the speciality and hence be able to be an important cogwheel of the national sports machinery. The National Medical Council (NMC) highlights the need of a competency-based curriculum for postgraduate training. Competency based training requires constant assessment and continuous feedback. This assessment needs to be at the workplace so as to register the journey of learning as and when it occurs. Post graduate students being adult learners are expected to reflect upon their learning experience. Portfolios are ideal for reflection and hence are considered different from logbooks which have no scope for the learner to reflect.4,5 Portfolios contain artefacts e.g., attendance records, list of procedures performed, project details, reflection of the student for the teaching learning experience, letter of appraisals, certificates, teacher learner interaction records and comments and any other supporting documents to the skills performed. Reflective learning is known to help the learner understand his own strengths and weaknesses and chart out a road map for better progress and attainment of competency.6 Portfolios are also an essential part of the workplace based assessment and can be planned for both summative and formative assessment.4,7, 8, 9, 10
Though the NMC does lay out guidelines, the onus lies on the teachers to ensure that the competencies of the curriculum are met. It is therefore important to define the activities an MD in Sports Medicine will be expected to do on conclusion of the course. Such activities have been defined as Entrustable Professional Activities (EPAs) and are explicit statements of what the learner should be able to do at the culmination of the training.11
There is a gap between anticipated and actual competence of these specialists, at times, due to lack of enlisting of EPAs and milestones. A lack of standardisation in the implementation of the curriculum not only affects the learner on a personal front but also jeopardises the conduct of their responsibilities that they are expected to deliver once they become a sports medicine specialist. The authors felt that there was a need to formulate EPAs with milestones and develop a portfolio to help implement a competency based curriculum for MD in sports medicine. The present study aims to address this need.
Material and methods
The study was done in the department of Sport Medicine of Armed Forces Medical College, Pune. The institute has been college associated with conducting the MD Sports Medicine course. The portfolio was developed in a stepwise method as depicted in Fig. 1. Initially, the faculty of the department were trained on the development of EPAs and milestones. The EPAs were then defined. Following this, milestones were developed for each EPA. The portfolio template developed by Datta et al was used as a model to finally enlist the EPAs and milestones so developed.12 The final step included a peer review by experts in the field from outside the institution to help refine the portfolio. Each step is further elaborated below.
Step 1
Faculty development
The Department of Medical Education of the institute conducted faculty development sessions for the core faculty of sports medicine regarding the process. The concept of EPAs and competencies and milestones was explained. The faculty then developed mock EPAs and milestones as a ‘hands on’ exercise which were discussed and feedback provided.
Step 2
Laying down of EPAs and Milestones
EPAs for MD sports Medicine were developed keeping the reference of the curriculum guidelines as laid out by NMC. Seven faculty members with no geographical limitations brainstormed and submitted their drafted EPAs. The entire curriculum was divided into broad sections which were further divided into segments and then each segment had the EPAs and milestones. Each segment was done by a minimum of five faculty members involved in teaching postgraduates.
Step 3
EPAs and milestones deconstructed into specifics using portfolio template
The EPAs and milestones so identified were populated in the template developed for the purpose by Datta et al,12 This template has been specially developed for use in a CBME curriculum and uses a EPA and milestone model. The portfolio also has fields for classifying the EPA into Vital/Essential and Desirable besides adding suggested teaching methods and assessment methods for each EPA. There is ample space provided for reflection by the learner and for the feedback by the facilitator in the portfolio.
Sports medicine being an integrated curriculum with multidisciplinary involvement, each EPA and milestone was allotted a phase completion timeline to ensure completion of the milestone in that particular phase of training, such that integration is possible.
Step 4
Designing the portfolio with intended achievement year
Each competency was now worked out into milestones along with its intended year of achievement. Each EPA had many milestones, many of them aligning in a temporal way in the same phase. Suggested teaching learning methods and assessment methods were mentioned.
Step 5
The final portfolio was assessed by other postgraduate teachers of the specialty and by postgraduate teaching faculty trained in medical education. They were free to remark/comment/suggest modifications. A time frame of fifteen days was kept for this final step. The comments, suggestions were discussed and the portfolio finalised.
Fig. 1.
Five Step Development of the Portfolio.
Results
The development of portfolio was done from July to September 2020. Three faculty members were trained by the Dept of Medical Education initially. These trained faculty in turn took a sensitisation workshop for six other faculty members of the speciality. The methodology of preparing EPAs/milestones and usage of the portfolio template was explained. All nine faculty members made the first draft of EPAs which was shared in e-format for approval and suggestions from others. A total of 18 members from specialty and 41 members of associated specialities including trained medical education faculty. After brainstorming the EPAs and milestones were completed. 114 EPAs, classified into 10 sections were finally approved by the experts from the entire curriculum. The list of segments and sections and the number of EPAs in each section is given in Table 1.
Table 1.
Details of various sections used in portfolio.
| Section | Segment | No. of EPAs |
|---|---|---|
| Exercise Physiology | Bioenergetics, Physiology of exercise & Sports performance | 22 |
| Exercise and Environmental Stress | ||
| Exercise and Special Populations | ||
| Clinical Sports Medicine | Fundamentals of Sports Injuries and Management | 44 |
| Sporting Emergencies Medical care | ||
| Regional - Sports Injuries | ||
| Non Traumatic Medical Conditions | ||
| Sports Injuries and Special Populations | ||
| Injury Prevention in Sports | ||
| Sports Team care including Medical assessment, Travel care, Ethics and Sexual harassment | ||
| Exercise Prescription for Clinical problems | ||
| Exercise and Public health | ||
| Sports Physiotherapy & Rehabilitation | Therapeutic modalities including Physical & Electrotherapy | 13 |
| Manual Therapy and Mobilization techniques | ||
| Rehabilitation principles and Therapeutic exercises | ||
| Functional Bandages and orthotics | ||
| Return to Sports criteria | ||
| General Theory & Methodological Training | Sports Training principles and Training methods | 4 |
| Physical fitness tests for health and sports performance | ||
| Workload monitoring methods | ||
| Talent Selection and long term development | ||
| Sports Biomechanics | Fundamentals of Kinesiology & Biomechanics in Sports performance and Injury management | 6 |
| Biomechanics of joints | ||
| Biomechanical Analysis of gait and common sports | ||
| Sports Nutrition | Nutrition in Sports performance and Injury management | 4 |
| Body composition, Weight control and Energy balance in Sports | ||
| Sports Psychology | Psychological aspects in Sports performance including personality, emotional control, attention, arousal, aggression, motivation and goal setting | 10 |
| Psychological Disorders in Sports including Post-injury Stress | ||
| Anti-Doping | Drugs and athlete | 3 |
| Anti-Doping Organisation, Rules, Prohibited lists, Dope control process and recent trends in doping | ||
| Research methodology, Medical Education and publications | Basic of Biomedical research and Biostatistics for Injury epidemiology studies | 8 |
| Research writing methods, Ethics in health research, grant proposal and Review of research articles, Basic principles of medical education | ||
| Total EPAs | 114 | |
Five faculty members deconstructed the EPAs and milestones of the segments allocated to them. In all 961 milestones were designed for the 114 EPAs. Each segment was brainstormed and suggestions noted. Seven revisions in all happened at Step 2 and 3. Three revisions were done at Step 4 and 5. The total time spent was two months for step 1 and 2, one month for step 3, and fifteen days for step 4 and 5.
The final proposed portfolio for MD Sports Medicine is available as Supplementary material. We also added a competency on ability to draft a lesson plan of all three domains of learning be it cognitive, psychomotor and/or affective domain. This was done specifically to enhance the skill of residents as doctors and a palpable need of our postgraduates as facilitators for short term courses in sports medicine, physical conditioners, coaches and even for undergraduates.13,14
Discussion
Developing a portfolio is essential for the successful implementation of a competency based curricula not only for learning but also for assessment.10 A portfolio not only documents the achievement of the competency but also supports it with all supportive evidence in the form of the record of learner–facilitator interaction, project reports, published material, attendance reports with detailed description of cases learnt. Along with this documentation, the comments of the teacher are endorsed and the reflections of the students while acquiring that competency are endorsed. The reflection done by the students adds value to the portfolio as it has been reported that reflective learning helps the learner facilitate the process of achieving these competencies.
Ten broad sections with segments within were chosen keeping in mind the necessity of keeping the focus on the speciality yet integrating it at an interdisciplinary level.15,16 Since the curriculum is interdisciplinary and the specialisation of sports medicine includes sports nutrition recommendations, providing psychological strengthening to the sportsmen and the coaches, physiotherapeutic prescription making, comprehensive planning of sports events apart from clinical acumen and theoretical background, the curriculum is essentially integrated. We have tried to include all the limbs of an interdisciplinary teaching i.e. contextualizing, conceptualizing, and problem-centring in our milestones for the EPAs.17 This portfolio will serve as a ready reference template for sports medicine postgraduates at other institutes too, however faculty needs to contextualise after brainstorming within their departments and then adapted.
Workplace based assessment (WPBA) has been added in the portfolio as assessment method. This was done to ensure possibility of assessment at an interdisciplinary level. It would be done using MiniCEX, patient survey forms, 360° evaluation, Direct observation of procedural skills (DOPS) and other methods when feasible.18, 19, 20 To effectively conduct WPBA, portfolio is an essential component of the WPBA tool box. It is extremely important therefore that a portfolio is completed by the postgraduates and is used for their assessment. The portfolios can also help in evaluation of the program, being an essential step for interdisciplinary programs.21
There is an existing gap in the ability of the postgraduates to be able to effectively teach and be groomed as effective teachers. More so, in sports medicine there is a huge responsibility of the specialist to teach the coaches and ancillary staff about the good practices to better performance of the sportsperson. Therefore, we have added it as an exclusive EPA. Similar findings were suggested by Snell et al and recently in 2020, Mahajan et al have also highlighted the same for Indian scenario.22,23
There are some limitations of this educational exercise. This set of EPAs have not been adopted or tried as of now in the residency. It does not replace existing pedagogy but attempts to serve as an add on. It is evident that there will be some areas that will need to be modified/fine-tuned as per the need of the Institute and that would become clearer as the process of attempting it to adopt it would be taken up to further evaluate and validate this proposed portfolio. Also, it is envisaged to be used as a physical copy given to the student to log the progress along with endorsements by the faculty. Over time, this process will need to be made in an electronic format.
This is a humble attempt to build a prototype for Indian setting and each Institute may be required to tailor make it based on some special requirements of the area/Institute. Further illustration of each EPA and milestone and to decide how to place it in the curriculum plan of training program is required by each Institute since it will depend on the availability of infrastructure and resources at each college.11
Conclusion
The MD Sports Medicine curricula is mandated to be competency based. The present exercise has attempted to frame the curricula in the form of EPAs and milestones using a CBME portfolio. 114 EPAs and 961 milestones have been identified and charted into the portfolio. This will help in the learners and facilitators focus their energy on helping the competent MD Sports Medicine graduate and deliver the skills learnt in post-graduation for the sports fraternity.
Disclosure of competing interest
The authors have none to declare.
Footnotes
Supplementary data to this article can be found online at https://doi.org/10.1016/j.mjafi.2020.12.026.
Appendix A. Supplementary data
The following is the Supplementary data to this article:
References
- 1.GUIDELINES FOR COMPETENCY BASED POSTGRADUATE TRAINING PROGRAMME FOR MD IN SPORTS MEDICINE: https://www.nmc.org.in/wp-content/uploads/2019/09/MD-sports-medicine.pdf.
- 2.Humphries D., Jaques R., Dijkstra H.P. A Delphi developed syllabus for the medical specialty of sport and exercise medicine. Br J Sports Med. 2018 Apr;52(8):490–492. doi: 10.1136/bjsports-2017-098477. [DOI] [PubMed] [Google Scholar]
- 3.Thompson B. Defining the sports medicine specialist in the United Kingdom: a Delphi study. Br J Sports Med. 2004 Apr 1;38(2):214–217. doi: 10.1136/bjsm.2003.004689. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Joshi M.K., Gupta P., Singh T. Portfolio-based learning and assessment. Indian Pediatr. 2015 Mar;52(3):231–235. doi: 10.1007/s13312-015-0613-2. [DOI] [PubMed] [Google Scholar]
- 5.Waghmare L., Srivastava T., Srivastava S. Portfolios for a reflective approach in learning. Natl J Physiol Pharm Pharmacol. 2016;6(3):263. [Google Scholar]
- 6.Sandars J. The use of reflection in medical education: AMEE guide No. 44. Med Teach. 2009;31(8):685–695. doi: 10.1080/01421590903050374. [DOI] [PubMed] [Google Scholar]
- 7.Modi J.N., Anshu Gupta P., Singh T. Teaching and assessing clinical reasoning skills. Indian Pediatr. 2015 Sep;52(9):787–794. doi: 10.1007/s13312-015-0718-7. [DOI] [PubMed] [Google Scholar]
- 8.Van Tartwijk J., Driessen E.W. Portfolios for assessment and learning: AMEE Guide no. 45. Med Teach. 2009 Jan;31(9):790–801. doi: 10.1080/01421590903139201. [DOI] [PubMed] [Google Scholar]
- 9.Williamson A. Building a portfolio. BMJ. 2011 Sep 15 [Google Scholar]
- 10.Sturmberg J.P., Farmer L. Educating capable doctors—a portfolio approach. Linking learning and assessment. Med Teach. 2009 Jan;31(3):e85–e89. doi: 10.1080/01421590802512912. [DOI] [PubMed] [Google Scholar]
- 11.Cate O. ten. An updated primer on entrustable professional activities (EPAs) Rev Bras Educ Méd. 2019;43(1 suppl 1):712–720. [Google Scholar]
- 12.Datta R, Raghavan D, Anand V, et al. Development of a portfolio framework for implementation of a outcomes based healthcare professional education curriculum using a modified e-Delphi method. Accepted in MJAFI (in this special issue 10.1016/j.mjafi.2020.12.031). [DOI] [PMC free article] [PubMed]
- 13.Cullen M. Sport and exercise medicine in undergraduate medical schools in the United Kingdom and Ireland. Br J Sports Med. 2000 Aug 1;34(4):244–245. doi: 10.1136/bjsm.34.4.244. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Carrard J., Pandya T., Niederhauser L., Infanger D., Schmidt-Trucksaess A., Kriemler S. Should sports and exercise medicine be taught in the Swiss undergraduate medical curricula? A survey among 1764 Swiss medical students. BMJ Open Sport Exercise Med. 2019 Aug;5(1) doi: 10.1136/bmjsem-2019-000575. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.The integration ladder: a tool for curriculum planning and evaluation. Med Educ. 2000 Jul;34(7):551–557. [DOI] [PubMed]
- 16.Klaassen R.G. Interdisciplinary education: a case study. Eur J Eng Educ. 2018 Nov 2;43(6):842–859. [Google Scholar]
- 17.Nikitina S. Three strategies for interdisciplinary teaching: contextualizing, conceptualizing, and problem-centring. J Curric Stud. 2006 Jun;38(3):251–271. [Google Scholar]
- 18.Tan J., Tengah C., Chong V.H., Liew A., Naing L. Workplace based assessment in an asian context: trainees' and trainers' perception of validity, reliability, feasibility, acceptability, and educational impact. J Biomed Educ. 2015:1–8. 2015 Dec 29. [Google Scholar]
- 19.Norcini J., Burch V. Workplace-based assessment as an educational tool: AMEE Guide No. 31. Med Teach. 2007 Jan;29(9–10):855–871. doi: 10.1080/01421590701775453. [DOI] [PubMed] [Google Scholar]
- 20.Singh T., Modi J.N. Workplace-based assessment: a step to promote competency based postgraduate training. Indian Pediatr. 2013 Jun;50(6):553–559. doi: 10.1007/s13312-013-0164-3. [DOI] [PubMed] [Google Scholar]
- 21.Misra S., Harvey R.H., Stokols D. Evaluating an interdisciplinary undergraduate training program in health promotion research. Am J Prev Med. 2009 Apr;36(4):358–365. doi: 10.1016/j.amepre.2008.11.014. [DOI] [PubMed] [Google Scholar]
- 22.Snell L. The resident-as-teacher: it's more than just about student learning. J Grad Med Educ. 2011 Sep 1;3(3):440–441. doi: 10.4300/JGME-D-11-00148.1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Mahajan R., Gupta P., Singh T. Training-module for residents in medical educational technologies (TRIM): need and operational strategies. Indian Pediatr. 2020 Oct;57(10):944–949. [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.