Rheumatology Advance Access originally published online on January 30, 2007
Rheumatology 2007 46(3):391-397; doi:10.1093/rheumatology/kel415
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
REVIEWS |
The development of an evidence-based educational framework to facilitate the training of competent rheumatologist ultrasonographers
Academic Unit of Musculoskeletal Disease, University of Leeds, Chapel Allerton Hospital, Leeds LS7 4SA, UK, 1Medical Education Unit, School of Medicine, University of Leeds, Leeds LS2 9NL, UK and 2Department of Radiology, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK.
Correspondence to: Dr Andrew K. Brown, Lecturer in Rheumatology, Academic Unit of Musculoskeletal Disease, University of Leeds, Chapel Allerton Hospital, Leeds LS7 4SA, UK. E-mail: andrewkbrown{at}ukonline.co.uk
 |
Abstract |
|---|
 Top Abstract IntroductionThe development of an...DiscussionAcknowledgementsReferences |
|---|
Objectives. Musculoskeletal ultrasonography (MSKUS) has been described by some rheumatologists as the ‘stethoscope of the joint’. Such enthusiasm is supported by evidence confirming validity and clinical utility in evaluation of musculoskeletal diseases. But if rheumatologist-performed MSKUS is to emulate the impact of cardiologist-performed echocardiography, a number of educational challenges need be addressed. Evaluation of current training reveals the absence of a unified educational structure, ad hoc teaching and assessment and published data are insufficient to make practice and training recommendations specific to rheumatology.
Methods. Informed by developments in adult-learning theory, we have utilized a competency-based approach to develop an educational programme for rheumatologist ultrasonographers. Fundamental to this process has been accurate functional analysis of the role of the rheumatologist ultrasonographer and precise translation of these data into educational outcomes. This involved a thorough, transparent, iterative, curriculum-defining approach, employing quantitative and qualitative research techniques including interview, questionnaire, Delphi and standard setting methodologies. All relevant stakeholders were engaged, including international US experts and clinical rheumatologists.
Results. Outcomes include clarification of the role of a rheumatologist ultrasonographer; definition of appropriate knowledge and skills; establishment of competency standards; a balanced, clearly defined, clinically relevant educational outcome blueprint. Teaching and assessment approaches have been piloted as part of an accessible modular curriculum strategy. Thorough validation and evaluation confirms effectiveness, efficiency and suitability.
Conclusions. A comprehensive evidence-based, expert consensus-defined educational framework is proposed that provides a template for teaching and learning and standards for competency assessment. This should facilitate common principles of training, uniform professional practice and a justifiable governance structure.
|
Introduction |
|---|
|
TopAbstractIntroductionThe development of an...DiscussionAcknowledgementsReferences |
|---|
Musculoskeletal ultrasonography (MSKUS) is considered to be one of the most important developments in rheumatology clinical practice in recent years [1–3]. MSKUS is a safe, versatile complementary ‘bedside’ clinical tool [4]. It not only offers the potential for the clinician to improve his or her diagnostic skills and management decisions, raising the standard of patient care [5], but it is also helpful to the researcher allowing improved understanding of the pathophysiology of rheumatic diseases [6, 7] and as an objective measure [8] and predictor [9] of disease outcome. Therefore, acquiring the necessary skills to perform this technique would appear to have many advantages to a rheumatologist. It is consequently becoming an integral part of rheumatology practice with an expanding evidence base to support its use in a wide range of musculoskeletal conditions [10]. Rheumatologists have embraced this imaging tool and increasing numbers now enthusiastically perform MSKUS examinations as part of their routine patient care [11].
However, despite the considerable interest within the rheumatological community and the recognition of the potential benefits to clinical practice, the future of MSKUS as a ubiquitous out-patient clinical tool used by all rheumatologists is uncertain. There is an urgent need for clarification as to the role of the rheumatologist ultrasonographer and establishment of training requirements [12]. In particular, the development of a robust educational infrastructure is required to provide opportunities for training and to ensure standards of competency are achieved and maintained [13, 14].
Although rheumatological MSKUS is an expanding area, the published information on training is currently limited [15–20]. The European League Against Rheumatism (EULAR) working group for MSKUS has produced some technical guidelines [15] and recently the Royal College of Radiologists has made a series of recommendations for ultrasound training for non-radiologists [19]. Short introductory courses in MSKUS are available at a national and European level but these aim to present basic concepts and aid understanding rather than provide formal training. In certain European countries, where rheumatologist-performed MSKUS is most established, for example Germany, Italy and Spain, MSKUS is being incorporated into their rheumatology postgraduate training. Research in this area has tended to concentrate on quantification of the learning curve in terms of feasibility and time to achieve a comparable standard of image acquisition when compared with experts [16–18]. However, there are not many data regarding approaches to teaching or assessment of competency and no unified agreement regarding an educational curriculum or certification. This is reflected in a wide variation in approaches to MSKUS education taken by rheumatologists, which is confirmed in a survey of EULAR delegates [11], which reports that most training is undertaken at a postgraduate level (87%) with attendance at a training course (46%) and informal training from an experienced colleague (51%), usually a rheumatologist or a radiologist, being the most common approaches.
Hence, at present, there is no clear training pathway or accreditation status for rheumatologists with an interest in MSKUS and consequently current education is commonly ad hoc and unregulated. However, there is a steep learning curve and whilst experts agree that specialized training is needed, there is relatively less agreement as to what constitutes adequate training or the process by which this should be achieved. Indeed, at present, there are no reliable criteria that define training requirements and, in general, insufficient data to inform the development of an educational process fit for this purpose. Assessment and quality assurance are also key requirements as competency (and hence patient safety) cannot be assured after merely participating in training and performing a minimum number of examination cases.
In an attempt to address these challenges, we have conducted a body of original research with the aim of developing an educational framework to facilitate the training of competent rheumatologist ultrasonographers. This article summarizes the sequential stages of this iterative curriculum-defining process that have informed the development of evidence-based educational outcomes and a competency-based curriculum structure. We propose that this framework should form the basis of the future education and practice of rheumatologist-performed MSKUS.
|
The development of an educational programme for rheumatologist performed MSKUS |
|---|
|
TopAbstractIntroductionThe development of an...DiscussionAcknowledgementsReferences |
|---|
The transition from novice ultrasonographer to competent and ultimately expert is a fundamental theme of this project. It is crucial to define what level of quality is represented by competence as well as accurately relating this to the role of a rheumatologist and the particular situations in which it is appropriate for them to perform a MSKUS examination. Within this structure, common or important tasks should form part of a competency ‘core-set’, whereas activities demanding a greater level of skill or occuring less frequently should be regarded as an extension of quality or role and be assigned accordingly. The subsequent challenge is to design an educational programme that can map such characteristics within an appropriate teaching and learning framework, including a system of assessment with the capability to accurately judge when such criteria are satisfied and a state of competence is achieved. A competency-based educational approach is proposed in order to achieve these goals. The principles of this approach involve the identification of task-specific skills, defining appropriate standards, and demonstrating satisfactory performance of such skills against the specific standard in order to be deemed competent [21].
To this end, a rigorous, systematic methodology has been employed in order to achieve these goals with each subsequent phase building on the data from the preceding analysis. This process has involved eight iterative stages and is summarized in Fig. 1.
|
Stage 1: Situational analysis
The project began with an extensive situational analysis, the purpose of which was to precisely establish what educational infrastructure was already in place. This consisted of a number of phases: review and critical appraisal of the MSKUS literature in order to elucidate the role of MSKUS in rheumatological practice; exploring developments in physician-performed MSKUS in other specialties as a potential model for rheumatologist training; analysis of the present international MSKUS educational infrastructure; review and critique of the existing MSKUS training literature and consultation with expert practitioners.
A cross-sectional evaluation study was conducted amongst international expert rheumatologist and radiologist ultrasonographers in order to provide more information regarding practice, training and assessment in MSKUS as well as to seek opinions regarding a proposed training pathway for rheumatologists [22]. This provided an interesting insight and highlighted differences in practice and confirmed that there was no unified approach to training or assessment. Most respondents identified participation in a formal training programme and a period of working with an expert practitioner as the most appropriate system of training. These data endorsed the aims of the project and corroborated the requirement for further educational research in order to inform the development of a relevant educational programme for rheumatologists.
Stage 2: Establish indications, anatomical areas and skills
The preceding analysis revealed an absence of any existing model on which to base an MSKUS educational programme for rheumatologists or any comprehensive published standards to act as a starting point for developing a system of training and assessment. Therefore, we sought to address a number of fundamental questions, namely to clarify the role of a rheumatologist ultrasonographer, and establish a consensus of those indications and anatomical areas that would be appropriate (or inappropriate) for scanning, together with the knowledge and skills that would be required to be deemed competent in MSKUS. To do this we recruited a panel of international experts in MSKUS. From an initial cohort of almost 60 experts, up to 40 were directly involved in the various stages of this project and comprised rheumatologist and radiologist ultrasonographers. All participants satisfied specific selection criteria, which included regular MSKUS practice, a track record of research and teaching and peer acknowledgement of their expert standing. It was assumed that this group of experienced professionals would be able to provide the most informed insights into practice and training as well as most appropriately address issues of competency and standard setting that would be raised during the course of this project. Established iterative Delphi methodology [23–25] was employed in order to determine consensus agreement, which resulted in the identification of a set of ‘best practice’ recommendations, specific to rheumatologists performing MSKUS [26].
Stage 3: Establish competency standards
The panel of international experts were asked to define the minimum standards required by a rheumatologist to be judged competent in MSKUS. They reviewed 115 MSKUS skills identified in Stage 2 and rated their relative importance according to specific criteria. Subsequent analysis has resulted in consensus agreement regarding specific levels of competency required for the rheumatology skill–set and the development of a competency-based model of specific learning outcomes and standards for education and practice [27].
Stage 4: Assess clinical utility and learning motivation
At this point, consideration was switched from the imaging experts to the rheumatologists i.e. the intended recipients of training. As important stakeholders in this educational process, rheumatologists were asked to describe their attitudes towards performing MSKUS examinations. The educational programme needed to include skills that were useful to their daily practice and that they would be motivated to learn in order for training to be worthwhile. Therefore, we conducted a study of rheumatologists in order to assess the clinical utility and their learning motivation of acquiring the skills deemed important by imaging experts [28], as well as assessing factors that may encourage or limit future dissemination of MSKUS skills amongst rheumatologists.
Stage 5: Integration of competency standards with clinical requirements
Competency standards from imaging experts were combined with clinical requirements and attitudes of rheumatologists with the aim of producing a balanced, clinically focused competency-based syllabus. In this way, the clinical need of rheumatologists and the competency standards of imaging experts have been acknowledged and important stakeholders have been engaged in the curriculum defining process. It was hoped that such ownership by all parties would increase the likelihood of an acceptable outcome which may improve future dissemination of skills.
Stage 6: Validation
A final validation phase was conducted whereby the integrated competency data and evolving educational outcomes were returned to the imaging experts for further review, reflection and comment. The experts were required to submit quantitative scores in relation to satisfaction (i.e. overall level of agreement) and appropriateness (i.e. suitability for routine rheumatology practice) as well as qualitative comments. Final modifications based on their critical appraisal completed the development of this competency-based framework. This culminated in the development of definitive competency-based educational outcomes (generic and pathology-based) in which levels of knowledge and skills have been divided into the specific categories, termed competency designations (Tables 1–4
).
|
|
|
|
The generic and pathology competency outcomes represent the evidence-based conclusions of the preceding six stages of this work with each MSKUS skill having been subject to iterative reflection and review by expert practitioners, culminating in consensus agreement. Table 3 is a key outcome of this work and depicts the rheumatology-specific MSKUS pathology competency outcomes and represents a blueprint, which shapes teaching and assessment in this section of the curriculum. The definition of each competency designation (‘Core’; ‘Option A: Intermediate’; ‘Option B: Advanced’) is outlined in Table 1. These definitions are fundamental to the philosophy upon which the curriculum framework is based, reflecting engagement of relevant stakeholders and the assignment of appropriate clinical relevance by rheumatologists and standards of competency by imaging experts. It represents a practical hierarchy combining clinical utility with competency. For example, core skills denote key areas where possessing MSKUS competence may provide a clinical advantage in daily rheumatology practice as well as defining the minimum standard of proficiency one may expect in order to guarantee reliable practice and thereby patient safety. Conversely, advanced skills may be not so relevant to the routine practice of a rheumatologist, yet may be of interest in a particular setting, and may require an increased level of knowledge and expertise over and above what is normally expected. This uniquely tailored approach, promoting the acquisition of clinically relevant skills whilst paying due consideration to important competency standards should encourage learning and dissemination of MSKUS in an environment best suited to the specific requirements of the busy clinical rheumatologist.
Stage 7: The pilot curriculum
The results of the educational development process form the basis of a comprehensive rheumatology MSKUS educational curriculum document, which includes structured competency-based content, an educational strategy, a teaching and assessment plan and evaluation and quality assurance agenda (Fig. 2). This is summarized as follows:
|
Content
The competency-based educational outcomes (Tables 1–4
) represent the content of the curriculum. The proposed training programme is delivered via two inter-linked educational processes in the form of an introductory course which aims to provide a uniform foundation for training, followed by an ‘on-the-job’ apprenticeship, which permits more diverse education and practice under the direction of a personal mentor. This provides key practical training opportunities with individual tuition and mentorship and comprises a series of core and elective modules as specified in the learning outcomes with the opportunity to select a unique training pathway comprising modules relevant to the individual practitioner.
Teaching
A variety of teaching approaches are utilized in order to maximize learning opportunities and provide the students with a balance of activities to suit their individual learning styles and requirements. These include a whole class lecture, small group tutorials, one-to-one teaching and self-directed learning. A variety of teaching tools have been employed including computer-generated slides and pictures; video and practical demonstration involving normal volunteers, patients and ‘phantom’ models; ‘real’ patients as part of an expert tutor's normal hospital practice; a comprehensive study guide to reflect the educational outcomes and provide a permanent educational resource. In addition, appropriate educational strategies comprising a spectrum of traditional and innovative approaches have been selected to deliver the goals of the programme.
Assessment
Assessment is an integral component of every curriculum. It not only drives learning by determining what and how a student learns [29] but it is also essential to determine whether predetermined standards have been achieved. The assessment process thereby helps to establish whether the aims and outcomes of the educational programme are satisfied, the content of the curriculum is appropriate and the methods of teaching are effective. All trainees are subject to regular assessment in order to measure the acquisition and application of knowledge and the development of skills and practical performance as they progress through the programme. This is conducted using the principles of Miller's pyramid model for assessing clinical competence [30]. This paradigm subdivides competency into knowing (knowledge base), knowing how (problem-solving), showing how (demonstration) and doing. It is the assessment of doing that provides a measure of real day-to-day professional performance and can be tested by direct observation in the work place and portfolio. The key to valid and reliable assessment is wide sampling across content using a variety of techniques and different assessors (Fig. 2). Such assessment is both summative and formative. Regular formative assessment is used as a method of constructive feedback for both teachers and students as part of an ongoing evaluation process. For the students this helps to guide further work by promoting learning through understanding by recognizing areas where the necessary requirements have been reached as well as identifying and motivating further study in areas of deficiency. For the teacher, this process may identify sections of the curriculum or teaching that require improvement. End-of-programme summative assessment determines whether the student has achieved the necessary predetermined standards and is competent in the practice of MSKUS. (This could be used to endorse a standard of performance and be recognized by appropriate certification.)
Stage 8: Implementation, delivery and evaluation
A commitment to evaluation has been an integral part of the development process. Its purpose is to provide information to enable subsequent modification and improvement, a key part of any new and evolving educational venture. A variety of techniques have been utilized for this purpose (Fig. 2). An extensive evaluation has already been conducted as part of the implementation and delivery of the pilot programme [31]. This involved delivery of the pilot educational programme to a target audience and subsequent analysis in order to assess the effectiveness of the approach in terms of increased knowledge and skills, the efficiency of the teaching and learning process and any long-term change in behaviour as a result of the educational interventions [31]. Using this approach, we have already been able to resolve immediate practical issues including advance distribution of course material, standardisation of teaching sessions between tutors using an instructor training workshop and revision of the teaching programme to include a specific session on machine orientation. In addition, this exercise has provided validation data confirming the effectiveness and efficiency of the educational process. A further endorsement of this approach has been demonstrated by the positive effect of education in stimulating personal and institutional change, which has been sustained over time. Preliminary evidence has also been obtained of positive effects on patient outcome which provides powerful information to support the impact of our educational interventions. A curriculum committee as well as an evaluation and quality assurance infrastructure has been established to coordinate subsequent similar exercises. Clearly, continued regular review, re-evaluation and audit of the whole training and assessment process are essential as modification and updating may inevitably be required. As the programme evolves, monitoring of resource usage and measurement of cost-effectiveness becomes increasingly important.
|
Discussion |
|---|
|
TopAbstractIntroductionThe development of an...DiscussionAcknowledgementsReferences |
|---|
Despite the undoubted popularity of MSKUS amongst non-radiologists, the established MSKUS practice by predominantly European rheumatologists and the increasing evidence base to support the use of MSKUS in areas of diagnosis, monitoring and intervention, there remain many educational challenges still to be addressed. Relevant unanswered questions include: for which indications should rheumatologist perform an MSKUS examination? What knowledge and skills do they require? What constitutes a competent ultrasonographer? How should they be trained? How do we ensure competency is achieved and maintained? This work has sought to provide some answers to these important questions and provide much needed evidence to inform the development of an educational infrastructure to facilitate the training of competent rheumatologist ultrasonographers. This has involved a systematic iterative process with each stage prompting reflection and re-evaluation as well as stimulating further study culminating in proposals for a framework of education and practice specific to MSKUS by rheumatologists.
A thorough appraisal of the educational literature prompted the choice of educational philosophy and methodology. The lack of established training infrastructure meant that considerable effort had to be made to develop a foundation of knowledge with which to inform the educational process. This represented the most resource-intensive part of the project. However, development of this curriculum framework corresponded with the philosophy of a competency-based methodology, as successful competency-based training requires a thorough process of identification of essential knowledge and skills required to perform a particular activity or else the procees is unlikely to be effective [21]. For this reason, this approach is justified, as it matches not only the goals of the project but also reflects the circumstances and environment in which this project has been developed.
Therefore, a large amount of work has been dedicated to assessing the specific needs of rheumatologists and identifying the particular MSKUS skills that they require in their clinical practice as well as the essential competency standards deemed necessary by imaging experts. Important stakeholders have been involved in this process, namely MSKUS experts who have proposed a consensus of competency standards, and rheumatologists who have ascribed clinical relevance to these skills. The resulting curriculum represents an appropriate balance of clinical utility and competency standards designed to specifically address the requirements of rheumatology MSKUS practice. It is hoped that such empowerment will encourage ownership and participation in MSKUS education and subsequent dissemination of skills.
Just as competence in a doctor (or rheumatologist ultrasonographer) is a sine qua non [32], the same is true of clearly defined, properly researched and explicit learning outcomes with respect to an effective educational programme. A well-constructed outcome template shapes a curriculum, as all its component parts, such as teaching, assessment and competency standards are constructed with direct reference to this model. Therefore, this extensive research to develop accurate, evidence-based educational outcomes, which relate to essential competency standards, is justified and the resultant curriculum is a reflection of this process.
The curriculum has been constructed to promote accessibility and flexibility. This is important as busy clinicians only have a finite time and opportunity to learn new skills and as adult learners may wish to only acquire knowledge in areas directly relevant to their particular interest or practice. A modular approach has been used to facilitate this with numerous elective components enabling students to select their own unique training portfolio. This also provides opportunities to study subjects of particular interest in greater detail. However, some skills remain fundamental to the safe practice of MSKUS and these core requirements have been defined by experts and remain compulsory for all.
As more evaluation data are collected, it will be possible to further optimize the teaching and assessment tools and other educational resources as well as clarify timing of competency assessment. Reliability and validity of these methods will need to be measured. Other educational resources could be developed, in particular, taking advantage of computer and web-based technologies. This may be particularly useful during the ‘on-the-job’ apprenticeship, which would lend itself to a web-based distance learning approach particularly as trainees may lack peer group contact and be geographically isolated from each other.
Dissemination is a further challenge and integration of this educational framework into rheumatology practice is required to enable universal access to opportunities for training in MSKUS. This may be improved by establishing a network of approved training centres, although systems would have to be in place to ensure uniformity of practice and education. Dissemination may be further expedited by consensus approval amongst relevant interested parties on curriculum and training standards and subsequent formal endorsement by external authorities representing rheumatology (e.g. BSR, EULAR), radiology (e.g. RCR, BMUS, BSSR) and the Royal Colleges (e.g. RCP, RCR). Formal accreditation or licensing by such bodies would also provide additional credibility and authenticity. In addition, an organisation is required to direct training and assessment as well as coordinate continued professional development and address issues of ongoing training, revalidation and clinical governance.
We hope that this research has begun to address some of the significant educational challenges of rheumatologists performing MSKUS. A thorough, systematic accumulation of evidence and expert testimony has resulted in establishment of clear, realistic and justifiable competency standards and the development of a validated curriculum framework specifically for the education of rheumatologist ultrasonographers. Broad stakeholder agreement regarding the competency outcomes required for the specialist rheumatologist ultrasonographer will facilitate common standards of training and uniform professional practice. This comprehensive, iterative approach to curriculum development should provide a universal structure for the training and assessment of rheumatologists in MSKUS as well as benchmark principles that will facilitate future informed decision-making and constructive competency-based educational development. This should represent a significant step forward in this important emerging rheumatology subspecialty discipline as well as providing an appropriate governance framework.
|
Acknowledgements |
|---|
|
TopAbstractIntroductionThe development of an...DiscussionAcknowledgementsReferences |
|---|
The Arthritis Research Campaign, by way of awarding A.K.B. an Educational Research Fellowship, funded this research.
The authors have declared no conflicts of interest.
|
References |
|---|
|
TopAbstractIntroductionThe development of an...DiscussionAcknowledgementsReferences |
|---|
- Canoso JJ. (2000) Ultrasound imaging: rheumatologist's dream. J Rheumatol 27:2063–64.[ISI][Medline]
- Balint P and Sturrock RD. (1997) Musculoskeletal ultrasound imaging: a new diagnostic tool for the rheumatologist? Br J Rheumatol 36:1141–42.
[Free Full Text] - Grassi W and Cervini C. (1998) Ultrasonography in rheumatology: an evolving technique. Ann the Rheum Dis 57:268–71.
- Manger B and Kalden JR. (1995) Joint and connective-tissue ultrasonography - a rheumatologic bedside procedure - a German experience. Arthritis Rheum 38:736–42.[ISI][Medline]
- Karim Z, Wakefield RJ, Conaghan PG, et al. (2001) The impact of ultrasonography on diagnosis and management of patients with musculoskeletal conditions. Arthritis Rheum 44:2932–33.[CrossRef][ISI][Medline]
- McGonagle D, Gibbon WW, O'Connor P, et al. (1999) A preliminary study of ultrasound aspiration of bone erosion in early rheumatoid arthritis. Rheumatology 38:329–31.
[Abstract/Free Full Text] - Falsetti P, Frediani B, Storri L, et al. (2002) Evidence for synovitis in active polymyalgia rheumatica: sonographic study in a large series of patients. J Rheumatol 29:123–30.[ISI][Medline]
- Wakefield RJ, Gibbon WW, Conaghan PG, et al. (2000) The value of sonography in the detection of bone erosions in patients with rheumatoid arthritis - a comparison with conventional radiography. Arthritis Rheum 43:2762–70.[CrossRef][ISI][Medline]
- Taylor PC, Steuer A, Gruber J, et al. (2004) Comparison of ultrasonographic assessment of synovitis and joint vascularity with radiographic evaluation in a randomized, placebo-controlled study of infliximab therapy in early rheumatoid arthritis. Arthritis Rheum 50:1107–16.[CrossRef][ISI][Medline]
- Kane D, Grassi W, Sturrock R, Balint PV. (2004) Musculoskeletal ultrasound - a state of the art review in rheumatology. Part 2: Clinical indications for musculoskeletal ultrasound in rheumatology. Rheumatology 43:829–38.
[Abstract/Free Full Text] - Wakefield RJ, Goh E, Conaghan PG, Karim Z, Emery P. (2003) Musculoskeletal ultrasonography in Europe: results of a rheumatologist-based survey at a EULAR meeting. Rheumatology 42:1251–53.
[Abstract/Free Full Text] - Speed CA and Bearcroft PWP. (2002) Musculoskeletal sonography by rheumatologists: the challenges. Rheumatology 41:241–42.
[Free Full Text] - Wakefield RJ, Brown AK, O'Connor PJ, Karim Z, Grainger A, Emery P. (2004) Musculoskeletal ultrasonography: what is it and should training be compulsory for rheumatologists? Rheumatology 43:821–22.
[Free Full Text] - Anonymous. (1998) Training in diagnostic ultrasound: essentials, principles and standards. Report of a WHO Study GroupWorld Health Organization Technical Report Series 875: pp. i–46.
- Backhaus M, Burmester GR, Gerber T, et al. (2001) Guidelines for musculoskeletal ultrasound in rheumatology. Ann Rheum Dis 60:641–49.
[Free Full Text] - Balint PV and Sturrock RD. (2001) Intraobserver repeatability and interobserver reproducibility in musculoskeletal ultrasound imaging measurements. Clin Exp Rheumatol 19:89–92.[ISI][Medline]
- Filippucci E, Unlu Z, Farina A, Grassi W. (2003) Sonographic training in rheumatology: a self teaching approach. Ann Rheum Dis 62:565–67.
[Abstract/Free Full Text] - D'Agostino MA, Maillefert JF, Said-Nahal R, Breban M, Ravaud P, Dougados M. (2004) Detection of small joint synovitis by ultrasonography: the learning curve of rheumatologists. Ann Rheum Dis 63:1284–87.
[Abstract/Free Full Text] - Board of the Faculty of Clinical Radiology. (2005) The Royal College of Radiologists. Ultrasound Training Recommendations for Medical and Surgical Specialties(Royal College of Radiologists, London) Report No.: RCR Ref No BFCR(05)2.
- Taggart A, Filippucci E, Wright G, et al. (2006) Musculoskeletal ultrasound training in rheumatology: the Belfast experience. Rheumatology 45:102–05.
[Abstract/Free Full Text] - Sullivan RS. (1995) The Competency-Based Approach to Training. JHPIEGO Strategy Paper # 1.
- Brown AK, O'Connor PJ, Wakefield RJ, Roberts TE, Karim Z, Emery P. (2004) Practice, training, and assessment among experts performing musculoskeletal ultrasonography: toward the development of an international consensus of educational standards for ultrasonography for rheumatologists. Arthritis Rheum-Arth Care Res 51:1018–22.
- Dalkey N and Helmer O. (1963) An experimental application of the Delphi method to the use of experts. Manage Sci 9:458–67.
- Lynn MR, Leyman EL, Englebardt SP. (1998) Nursing administration research priorities: a national Delphi study. J Nurs Admin 28:7–11.
- McKenna HP. (1994) The Delphi technique - a worthwhile research approach for nursing. J Adv Nurs 19:1221–25.[CrossRef][ISI][Medline]
- Brown AK, O'Connor PJ, Roberts TE, Wakefield RJ, Karim Z, Emery P. (2005) Recommendations for musculoskeletal ultrasonography by rheumatologists: setting global standards for best practice by expert consensus. Arthritis Rheum-Arth Care Res 53:83–92.
- Brown AK, O'Connor PJ, Roberts TE, Wakefield RJ, Karim Z, Emery P. (2006) Ultrasonography for rheumatologists: the development of specific competency based educational outcomes. Ann Rheum Dis 65:629–36.
[Abstract/Free Full Text] - Brown AK, Roberts TE, Wakefield RJ, et al. (2007) The challenges of integrating ultrasonography into routine rheumatology practice: addressing the needs of clinical rheumatologists. Rheumatology [10.1093/rheumatology/kel412 Epub ahead of print].
- Newble D. (2002) Assessment. In Norman GR, van der Vleten CPM, Newble DI (Eds.). International Handbook of Research in Medical Education(Kluwer, London) pp. 645.
- Miller GE. (1990) The assessment of clinical skills/competence/performance. Acad Med 65:Suppl, S63–7.[ISI][Medline]
- Brown AK, Wakefield RJ, Karim Z, Roberts TE, O'Connor PJ, Emery P. (2005) Evidence of effective and efficient teaching and learning strategies in the education of rheumatologist ultrasonographers: evaluation from the 3rd BSR musculoskeletal ultrasonography course. Rheumatology 44:1068–69.
[Free Full Text] - Talbot M. (2004) Monkey see, monkey do: a critique of the competency model in graduate medical education. Med Edu 38:587–92.
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  I. Atchia, F. Birrell, and D. Kane A modular, flexible training strategy to achieve competence in diagnostic and interventional musculoskeletal ultrasound in patients with hip osteoarthritis Rheumatology, October 1, 2007; 46(10): 1583 - 1586. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||