Skills training and education in orthopaedics for general practitioners play an important role in areas with low surgeon density because task shifting of patient care to primary care physicians is used to compensate for the lack of specialists in low to middle-income countries1. In southern Africa, this is often caused by geographic and sectorial maldistribution2, limited training opportunities3,4, brain drain5,6, and socioeconomic inequities7,8. Thus, most of the continent’s orthopaedic care is provided by nonspecialists, which makes adequate training and transfer of knowledge and skills to general practitioners paramount, especially during medical school.
The development of a structured curriculum for these health-care professionals should start with the identification of the most pertinent problems and a general needs assessment before objectives and aims can be established9. Ultimately, a curriculum for medical student training should be informed by local experts in order to prepare students for the local burden of disease and the accompanying challenges. Curricula should specifically target educational needs in a resource-restricted environment, as found in southern Africa, and address common local pathology.
The aim of this study was to find consensus among a group of African and international orthopaedic specialists and related experts on a list of knowledge topics, clinical presentations, and skills that are relevant to medical students in southern Africa in their preparation to provide primary care to orthopaedic patients.
Materials and Methods
A modified Delphi consensus study in the form of 3 interactive iterative rounds of communication and the prioritization of items10–12 by local and international experts and trainees was conducted between November 2018 and January 2019.
Participants
An invitation was sent out to participants via email requesting voluntary participation by those who were directly affected by orthopaedic teaching, such as local family physicians, general practitioners, interns, and medical students. Furthermore, orthopaedic specialists involved in medical student education and those practicing or involved in medical education in southern Africa were approached to take part. These participants were from various countries in southern Africa, North America, and Europe. They worked or trained in academic institutions as well as in primary care and secondary care facilities.
Iterations and Timing
In the first round, using free text, participants were asked to identify the most important topics relevant to primary care that they think should be included in the undergraduate medical curricula in southern Africa. These topics were grouped into 3 categories: knowledge topics, symptom-based cases, and skills. There was no word or character limit. After this first round, similar responses were merged to create larger themes or categories by a panel of 5 investigators (M.F.G.H., M.L., P.N., V.N., and N.K.). This panel was blinded to the identifiable information of the participants, specifically the participants’ names, affiliations, or geographic location. Irrespective of participation in the previous round, the questionnaire with these categorized topics was sent out to participants in the second round in order to prioritize the items. For this round, participants were provided with all of the responses regarding the 3 aforementioned categories (knowledge topics, cases, and skills), but were allowed to choose a maximum of 50% of the items that were listed within each category. Participants were blinded to each other’s responses, and an opportunity for additional comments was given. In the third round, feedback on the prioritization of the previous round was given in the form of a graphic display of the percent agreement per item. Participants were asked to reevaluate the respective items with this additional knowledge of the responses of the other participants. Overall, the entire Delphi process occurred over a 3-month period. There was a 2-month window between the first and second rounds and a 3-week window between the second and third rounds13,14. An initial invitation and 2 reminders at 1, 2, and 3 weeks were sent out for each round. All of the responses were anonymized prior to circulation. The data collection was performed electronically using REDCap (Research Electronic Data Capture) tools that are hosted at the study’s main institution. This is a secure, web-based application that was designed to support data capture for research studies15.
Data Analysis
Descriptive statistics were used to analyze the questionnaires and consensus agreement. To describe the study population, normally distributed continuous data were summarized by the mean, standard deviation (SD), and a 95% confidence interval, and non-normally distributed continuous data were summarized by the median and interquartile range. Categorical data were summarized as proportions with a 95% confidence interval. In the Delphi process, agreement was defined as a percent agreement of ≥75%.
Sample Size
Delphi studies do not call for statistical representativeness of the sample, and the principles of other surveys do not apply. A number ranging from 10 to 15 experts often is acceptable to most authors of articles about the Delphi process13,16, but most Delphi studies have used between 15 and 20 participants17 and usually have a maximum of 5018. In a heterogeneous sample size with different disciplines, 5 to 10 participants per group can add to the representation in the pool19. For the purposes of this study, we had a target number of 15 participants. Informed consent was obtained prior to participation, and the study was approved by the local review board.
Results
Participants
A total of 43 experts (32 men, 11 women; mean age, 41 years; SD, 9 years) who had a mean of 11 years (SD, 10 years) in clinical or academic practice participated in the study; 32 (74%) completed the first round, 18 (42%) completed the second round, and 25 (58%) completed the third round. Most were orthopaedic surgeons (31, 72%), followed by family medicine specialists and general practitioners (6, 14%), postgraduate medical interns (3, 7%), medical graduates completing a nonclinical postgraduate degree (2, 5%), and medical students (1, 2%). Thirty-two of the participants were from South Africa, 2 were from Namibia, and there was 1 each from Zambia, Tanzania, Ghana, Malawi, and Kenya. There was 1 expert from the United Kingdom and 1 from Canada, and 2 were from the United States (Fig. 1). Participants were involved in a wide range of clinical or academic practice, affiliation, and level of care. Most of the participants were affiliated with a university hospital (Table I).
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Fig. 1: Geographic distribution of experts who took part in this consensus study. Dark blue = >30 participants, light blue = ≤2 participants.
TABLE I -
Affiliations of Participants in the Delphi Study
| Affiliation |
No. |
% |
| University hospital |
26 |
60.5 |
| Secondary level hospital |
8 |
18.6 |
| Primary care facility |
3 |
7.0 |
| General practice |
1 |
2.3 |
| Health ministry |
3 |
7.0 |
| Other |
2 |
4.7 |
List of Topics, Skills, and Cases
The initial suggestions of important topics were used to extract symptom-based cases, knowledge topics, and skills. These topics were sent back to the experts for prioritization in the second and third rounds, and were ranked according to percent agreement (Tables II and III). More than 75% of the experts prioritized the cases that included patients with multiple injuries, a limping child, and orthopaedic emergencies. Consensus also was reached on teaching skills related to the manipulation of dislocations and fractures, as well as the examination of joints and casting techniques. Additionally, experts agreed that transferred knowledge should include the topic of orthopaedic infections, the principles of fracture management, the treatment of common fractures and dislocations, red flags alerting to specialist referral, approach to radiographs, and back pain (Table II). Although detailed ranking regarding subgroups within these items was not feasible, in their comments, many experts mentioned that orthopaedic infections should specifically include tuberculosis (TB) and the effect of human immunodeficiency virus (HIV) on orthopaedic conditions. A treatment approach to acute and chronic bone and joint sepsis, as well as the recognition of postoperative sepsis, were seen as important aspects of orthopaedic infections. Comments regarding the teaching of fracture management highlighted the importance of nonaccidental injuries, especially in children. Certain items had a <10% agreement after the third round of the consensus process (Table III). Fractures, soft-tissue injuries, and orthopaedic emergencies were prioritized and ranked separately. Within these groups, fractures of the hip, ankle, and distal aspect of the radius, along with open fractures and compartment syndrome as well as shoulder dislocation and soft-tissue ankle injuries, were ranked highest (Table IV). However, in their comments, many participants noted that all of the listed fractures, dislocations, and emergencies need to be included in a curriculum, and lower-ranked items should not be excluded.
TABLE II -
Cases, Skills, and Knowledge with a Percent Agreement of ≥75%
| Cases |
|
| Approach to patient with multiple injuries |
80% |
| Limping child |
76% |
| Orthopaedic emergencies |
76% |
| Skills |
|
| Manipulation of dislocations |
100% |
| Casting techniques |
88% |
| Manipulation of fractures |
84% |
| Examination of joints |
80% |
| Knowledge |
|
| Orthopaedic infections |
92% |
| Management of common fractures |
84% |
| Red flags alerting to specialist referral |
80% |
| Back pain |
80% |
| Principles of fracture management |
80% |
| Approach to radiographs |
76% |
| Common dislocations |
76% |
TABLE III -
Cases, Skills and Knowledge for Which No Consensus of ≥75% Agreement Was Reached
| Cases |
|
| Spinal trauma |
72% |
| Extremity fractures |
72% |
| Swollen, painful joint |
68% |
| Pediatric fractures |
64% |
| Approach to injured child |
60% |
| Neurologic symptoms |
56% |
| Joint and soft-tissue injury |
56% |
| Soft-tissue or osseous mass |
48% |
| Approach to bone lesion on radiograph |
44% |
| Swollen painful limb |
32% |
| Low-energy fracture |
24% |
| Multiple painful joints |
20% |
| Overuse injury |
16% |
| Atraumatic painful joints/spine |
12% |
| Deformed foot in child (atraumatic) |
8% |
| Spinal deformity |
8% |
| Limp in adult |
4% |
| Limb deformity |
4% |
| Skills |
|
| Back slabs/splints |
68% |
| Neurologic examination |
68% |
| Cervical traction |
60% |
| Intra-articular injection |
56% |
| Skin traction |
52% |
| Wound debridement |
48% |
| Thomas splint |
44% |
| Collar and cuff sling |
44% |
| Analgesia |
36% |
| External fixation |
32% |
| Skeletal traction |
28% |
| Joint aspiration |
28% |
| Arthrotomy |
20% |
| Skin-grafting |
20% |
| Osteitis drainage |
20% |
| Open reduction and internal fixation |
8% |
| Braces |
4% |
| Tendon repair |
4% |
| Peripheral nerve blocks |
4% |
| Knowledge |
|
| Osteoarthritis |
68% |
| Open fractures |
68% |
| Pediatric fractures |
68% |
| Spinal cord injury |
56% |
| Common bone tumors |
52% |
| Nerve injuries |
48% |
| Hand infections |
48% |
| Common hand conditions |
44% |
| Spinal trauma |
44% |
| Complications of fractures |
36% |
| Osteoporosis |
32% |
| Metastatic disease in bone |
24% |
| Common soft-tissue injuries |
24% |
| Common spine conditions |
20% |
| Knee injuries |
20% |
| Inflammatory arthritis |
16% |
| Clubfeet |
12% |
| Congenital conditions of orthopaedic importance |
12% |
| Orthopaedic manifestation of sickle cell disease |
12% |
| Arthroplasty |
0% |
| Dysplasia |
0% |
| Skeletal development |
0% |
| Spinal deformity |
0% |
TABLE IV -
Percent Agreement Among Experts After the Third Round, Specific to Fractures, Soft-Tissue Injuries, and Orthopaedic Emergencies
*
| Fractures |
|
| Ankle fracture |
92% |
| Hip fracture |
88% |
| Distal radial fracture |
80% |
| Femoral fracture |
68% |
| Tibial fracture |
60% |
| Forearm fracture |
44% |
| Elbow fracture |
28% |
| Foot fracture |
24% |
| Clavicular fracture |
24% |
| Humeral fracture |
24% |
| Knee fracture (periarticular) |
20% |
| Proximal humeral fracture |
20% |
| Soft-tissue injuries |
|
| Shoulder dislocation |
88% |
| Ankle injury |
76% |
| Hand injury |
52% |
| Knee dislocation |
48% |
| Hip dislocation |
40% |
| Knee injury |
28% |
| Elbow dislocation |
28% |
| Lower limb |
16% |
| Shoulder injury |
8% |
| Orthopaedic emergencies |
|
| Open fractures |
84% |
| Compartment syndrome |
72% |
| Acute bone and joint infections |
68% |
| Spinal injuries with neurologic deficit |
48% |
| Postoperative orthopaedic infections |
16% |
| Fat embolism |
12% |
*Participants were limited to selecting half of the items in each category.
Discussion
This consensus study, which was rooted in southern Africa, included a wide geographic, clinical, academic, and expertise-specific footprint of experts. A list of topics for medical students in southern Africa was established in which knowledge topics, skills, and cases in orthopaedic trauma and infections were prioritized.
Participants
As with other studies that have established a curriculum for undergraduate medical education, most of our experts were both educators and specialists20–22. However, more than one-quarter of the participants had subjective expertise and were general practitioners or junior trainees, which is unique in the design of an orthopaedic curriculum. Four international experts based outside of Africa were approached, specifically for their academic interest and expertise in medical education in Africa. The insight of these participants allowed us to focus the study around the future primary health-care practices of medical students in southern Africa23 but also included a global perspective. Furthermore, a large proportion (28%) of experts worked in general practice, primary-level facilities, or secondary-level facilities, and most (91%) were from Africa. This study provided insight on the orthopaedic conditions and challenges that are commonly seen in southern Africa, especially within the environment of the general practitioner1. This Africa-centered view with local participation of individuals from different levels of practice and expertise is an important cornerstone for further growth of a viable regional orthopaedic educational system24.
List of Topics, Skills, and Cases
Most of the skills and knowledge topics with high priority were related to the diagnosis and care of infections, including TB and HIV-related conditions, as well as orthopaedic trauma (Table II). Thus, patients with multiple injuries, a limping child, and orthopaedic emergencies were rated as the most important cases. “Red flags alerting to specialist referral” was a category that was prioritized by 80% of participants, alongside various nonoperative treatment skills for conditions not needing surgical intervention or to use as initial treatment, which is crucial to reduce unnecessary referrals and to increase the access to specialists for appropriate cases. These priorities also are included in the 35 most important topics in the National Undergraduate Curriculum in Surgery that is published by the Royal College of Surgeons in England25, as well as in the syllabus of the British Orthopaedic Association (BOA), although specific conditions such as TB or HIV are not their focus. In opposition to the BOA syllabus, nonurgent conditions and knowledge of surgical treatment such as open reduction and internal fixation, tendon repair, or peripheral nerve blocks, as well as higher-level topics such as arthroplasty and spinal or limb deformity, reached low agreement. Some participants gave a higher priority to skills for urgent surgical treatment such as wound debridement, external fixation, skeletal traction, skin-grafting, and osteomyelitis drainage, which suggests a greater amount of task shifting in their setting and points toward the variation of surgeon density among participating countries in this study. The inclusion of these skills should be considered, and adjustment of the curriculum for specific local circumstances might be necessary. The application of cervical reduction and traction was prioritized by 60% of participants because access to emergency spinal surgery is often compromised in their settings, but there are medicolegal implications if these patients do not undergo reduction26. Interestingly, despite the educational focus for primary health-care workers to recognize and treat foot deformities in children27, this topic was not prioritized by many.
Overall, this list of knowledge topics, skills, and cases provides a guideline for the implementation of a number of pedagogical approaches, ranging from case-based collaborative learning28 to experience-based learning29 and a more conventional curriculum of lectures. We realize that it is challenging to accommodate this curriculum in the short orthopaedic rotations in our medical student programs since musculoskeletal education is frequently underrepresented (and not just on our continent)30,31. This calls for an increase in student contact time that is appropriate for a field with the highest hospital episodes25 and surgical system burden, especially in southern Africa32. Otherwise, further condensation of this list to only the top priorities will be necessary.
Limitations
The iterations of this study varied in the number of participants but this is a common challenge in Delphi studies, and we reached our target of ≥15 participants in each round. Also, most of the participants were orthopaedists from academic institutions, which might have overshadowed the insights of primary care physicians. Although one-third of the participants were from the audience to whom this curriculum is directed, concerns unique to nonorthopaedists could still have been ranked lower in the aggregation process between phases 1 and 2 of the study. Furthermore, most participants worked in South Africa, potentially skewing the curriculum toward clinical challenges and conditions specific to that country. However, the geographic distribution of participants in this study correlates with the density of orthopaedic surgeons per country2. Furthermore, consensus was reached only for a few items, and adjusting the limit of possible answers to a higher value than 50% would have certainly increased the chance of consensus per item. Furthermore, detailed information within larger groups of topics such as fractures or infections might have been lost with the categorization after the first round, but the comments of the participants were provided to highlight these challenges and provide additional information.
Conclusions
This list of knowledge topics, skills, and case presentations is mainly based on insights from clinicians in southern Africa, with input from experts in medical education from the U.S., Canada, and the U.K. It highlights the need to teach knowledge topics and skills for the management of urgent conditions such as orthopaedic trauma and infections. Higher-level surgical skills to manage these conditions were suggested by participants in areas with a low density of surgeons. Nonoperative skills to manage orthopaedic conditions also were prioritized, which is important to keep the burden on orthopaedic-specialist services low.
Future studies should refine this list through further iterations with subjective experts, including medical interns, medical officers, and primary care physicians. The items in this list also should be examined against available clinical metrics such as diagnoses in primary care facilities or after referrals to specialists. This list might be transferable to other countries and continents, but it should be adjusted for local problems and needs and should be data-driven if possible. It will also allow insight for national discussions concerning the allocation of student contact time during orthopaedic and trauma rotations.
Note: The Learning Innovation via Orthopaedic Networks (LION) Group includes Rueben K.S. Ngissah, Accra, Ghana; Nicholas Lubega, Blantyre, Malawi; Mark Nortje, Robert Dunn, Anria Horn, Michael Solomons, Maritz Laubscher, Nando Ferreira, Stephen Roche, Thomas Hilton, Beverley Schweitzer, Graham McCollum, Nabeela Kajee, Nicholas Kruger, Matthew Potter, Sithombo Maqungo, Vela Njisane, Phinda Njisane, Tasleem Ras, Duncan McGuire, Elsje M. de Vries, Mosedi Namane, William Langenhoven, David North, Ntambue Kauta, Simon M. Graham, Cape Town, South Africa; Bill Haonga, Dar Es Salaam, Tanzania; Leonard C. Marais, Durban, South Africa; Theodorus L.B. Le Roux, Glenstantia, South Africa; Carel Bezuidenhout, Kimberly, South Africa; Nicholas Bernthal, Los Angeles, California; James C. Munthali, Lusaka, Zambia; Moses Kimani, Nairobi, Kenya; Sariah Khormaee, New York, NY; Jim Turner, Oxford, England; Damian Thomas, Catherine Makepeace, Christina Wu, Benjamin Garrett, Port Elizabeth, South Africa; Mthunzi Ngcelwane, Pretoria, South Africa; L. Visser, Vredenburg, South Africa; and Cobus Moolman and Sibasthiaan Shituleni, Windhoek, Namibia.
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