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SPINE Volume 41, Number 6, pp 530–537ß 2016 Wolters Kluwer Health, Inc. All rights reservedHEALTH SERVICES RESEARCHDevelopment of a Competence-Based SpineSurgery Fellowship Curriculum Setof Learning Objectives in CanadaJeremie Larouche, MD, Albert J. M. Yee, MD,y Veronica Wadey, MD,y Henry Ahn, MD,yDouglas M. Hedden, MD,z Hamilton Hall, MD,y Robert Broad, MD,y Chris Bailey, MD,§Andrew Nataraj, MD,z Charles Fisher, MD,{ Sean Christie, MD,jj Michael Fehlings, MD,yPaul J. Moroz, MD, Jacques Bouchard, MD,yy Timothy Carey, MD,§ Michael Chapman, MD,§§Donald Chow, MD, Kris Lundine, MD,{{ Iain Dommisse, MD,{{ Joel Finkelstein, MD,yRichard Fox, MD,z Michael Goytan, MD,{{ John Hurlbert, MD,yy Eric Massicotte, MD,yJerome Paquet, MD,y Jan Splawinski, MD,jjjj Eve Tsai, MD, Eugene Wai, MD, Brian Wheelock, MD, and Scott Paquette, MD {Study Design. Modified-Delphi expert consensus method.Objective. The aim of this study was to develop competencebased spine fellowship curricula as a set of learning goalsthrough expert consensus methodology in order to provide aneducational tool for surgical educators and trainees. Secondarily, we aimed to determine potential differences amongspecialties in their rating of learning objectives to definedcurriculum documents.Summary of Background Data. There has been recentinterest in competence-based education in the training of futuresurgeons. Current spine fellowships often work on a preceptorbased model, and recent studies have demonstrated thatFrom the Laval University,Quebec City, Quebec; yUniversity of Toronto,Toronto, Ontario, Canada; zUniversity of Alberta, Edmonton, Alberta, Canada; §University of Western Ontario, London, Ontario, Canada; {Universityof British Columbia, Vancouver, British Columbia, Canada; jjDalhousieUniversity, Halifax, Nova Scotia, Canada; University of Ottawa, Ottawa,Ontario, Canada; yyUniversity of Calgary, Calgary, Alberta, Canada; §§TheScarborough Hospital, Scarborough, Ontario, Canada; {{University of Manitoba, Winnipeg, Manitoba, Canada; jjjjVernon Jubilee Hospital, Vernon, BC;and Saint John Regional Hospital, Saint John, NB.Acknowledgment date: August 18, 2015. Acceptance date: September 7,2015.The manuscript submitted does not contain information about medicaldevice(s)/drug(s).No funds were received in support of this work.Relevant financial activities outside the submitted work: board membership,consultancy, grants, royalties, stocks, expert testimony, employment, payment for lectures, travel/accommodations/meeting expenses.Address correspondence and reprint requests to Dr Jeremie Larouche, MD,University of California San Francisco—Orthopaedic Trauma Institute,2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA 94110;E-mail: Jeremie.Larouche@UCSF.edugraduating spine fellows may not necessarily be exposed to keycognitive and procedural competencies throughout their trainingthat are expected of a practicing spine surgeon.Methods. A consensus group of 32 spine surgeons from acrossCanada was assembled. A modified-Delphi approach refined aninitial fellowship-level curriculum set of learning objectives (108cognitive and 84 procedural competencies obtained from opensources). A consensus threshold of 70% was chosen with up to5 rounds of blinded voting performed. Members were asked toratify objectives into either a general comprehensive or focused/advanced curriculum.Results. Twenty-eight of 32 consultants (88%) responded andparticipated in voting rounds. Seventy-eight (72%) cognitiveand 63 (75%) procedural competency objectives reached 70%consensus in the first round. This increased to 82 cognitive and73 procedural objectives by round 4. The final curriculumdocument evolved to include a general comprehensive curriculum (91 cognitive and 53 procedural objectives), a focused/advanced curriculum (22 procedural objectives), and apediatrics curriculum (22 cognitive and 9 procedural objectives).Conclusion. Through a consensus-building approach, thestudy authors have developed a competence-based curriculumset of learning objectives anticipated to be of educational valueto spine surgery fellowship educators and trainees. To ourknowledge, this is one of the first nationally based efforts of itskind that is also anticipated to be of interest by internationalcolleagues.Key words: clinical fellowship, competency-based, curriculumdesign, medical education, spine, surgical education, teaching.Level of Evidence: N/ASpine 2016;41:530–537DOI: mMarch 2016Copyright 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

HEALTH SERVICES RESEARCHTDevelopement of a Competence-Based Spine Fellowship Larouche et alhe field of spine surgery has advanced rapidly overthe past 2 decades. With new technologies and newprocedures, the breadth and scope of the practice of aspine surgeon has become so broad that it can no longer becovered adequately during the course of residency training.1Combined with new residency duty hours restriction thatare in effect in the United States (U.S.), the United Kingdom(U.K.), and now in Canada, this has led many to questionwhether residents are truly ready to enter practice upongraduating from surgical residencies,1–4 and even whetherspine surgery should become its own surgical residency.5Sub-specialization fellowships have and continue to play animportant role in ensuring that surgeons obtain the highestquality of training so that they may in turn provide exceptionalpatient care within a specific area of surgery. After graduatingfrom a fellowship, the expectation is that a surgeon will becompetent in performing a variety of elective procedures, aswell as to manage a multitude of surgical emergencies andcomplications. However, fellowships are not uniform. Manyspine surgery fellowships function on a preceptorship basis,where mentors may have a particular interest in fields such asdeformity, trauma, or degenerative disease. This does notnecessarily reflect a more general spine practice that fellowsmay encounter upon entry into independent practice. A surveyby Konczalik et al1 demonstrated significant variability insurgeons’ self-reported confidence in performing various coreprocedures following spine fellowship training in Europe. Theyconcluded that ‘‘there is a considerable variation in the competency of post-fellowship spinal surgeons in the managementof frequently encountered spinal conditions’’ and raise the issueof ‘‘a lack of uniformity in the surgical curriculum’’.1 Malempati et al6 recently performed a similar study in Canadasurveying spine fellows upon graduation to assess their selfperceived competence at performing 29 key procedures independently. Of those procedures, fellows indicated being comfortable in independently performing 12 of the 29, requiring ‘‘alittle more training’’ for 13 procedures, and ‘‘some more training’’ for the remaining 4.Herkowitz et al,7 through the North American SpineSociety (NASS), highlighted the importance of a fellowshipeducational curriculum among other factors that traineesshould consider in selecting a clinical fellowship.8 To date,there is limited published literature on spine surgery fellowship education and there remains an important need todevelop and validate educational curricula including evaluation methods on the acquisition of clinical skills. Theestablishment of a nationally based education curriculaset of learning objectives at the spine surgery fellowshiplevel was the primary purpose of this study. This wasconsidered a key goal toward enhancing education, including research in education. Secondarily, we aimed to determine potential differences among specialties in their ratingof learning objectives to defined curriculum documents.of the scientific literature. We obtained these objectives byevaluating educational and continuing medical educationmaterials available through training programs, international spine societies, as well as physician surgical accreditation organizations. Objectives were also included on thebasis of perceived gaps in training syllabi as deemed appropriate by expert group members. An initial list of fellowshiptraining objectives included 108 cognitive and 84 procedural competency objectives.A consensus group of 32 academic and community spinesurgeons was established through the Canadian SpineSurgery (CSS) Education Committee (Chair author S.P.).This group was composed of neurosurgeons and orthopedicsurgeons whose practice consisted of at least 80% spinesurgery, and represented national academic and communityinterest. Table 1 provides further description of the expertgroup’s composition and experience. The expert groupdefined a priori several terms that were used to evaluatethe listed objectives (Table 2).A modified-Delphi expert method was employed and theinitial list of training objectives was voted upon anonymouslyusing an online electronic ballot (SurveyMonkey). After eachround of voting, learning goals that achieved 70% consensuson a defined rating scale (Table 2) were eliminated, transferred to the comprehensive fellowship curriculum, or to thefocused/advanced fellowship curriculum.9 Those that failedto reach consensus were discussed and revised before beingsubmitted to the next round of voting, until a 70% consensusagreed to the modification. A maximum of 5 rounds wasagreed upon before the commencement of ratification. Onceall objectives were assigned to their respective subcategory,the expert group ratified curricula documents as a whole.Statistical analysis was performed by a biostatistician(J.C.V.) using SAS v9.4 (Cary, NC). Between our neurosurgicaland orthopedic respondents, we compared the distribution ofsurgical practice type, fellowship/program director status, andgeographic region of practice by province (Fisher’s exact test).We also compared years in clinical practice and number ofclinical fellows trained (Wilcoxon rank-sum test). We thenanalyzed for potential differences in how respondents initiallyrated each cognitive and procedural objective comparingorthopedic with neurosurgical respondents (Fisher’s exact test).A grouped analysis of cognitive (e.g., trauma, oncology, etc.)and procedural (e.g., cervical, thoracic, etc.) ratings was alsoperformed comparing specialty background (Bonferroni corrected non-parametric Wilcoxon rank-sum tests looking for adifference in the distribution of responses). We determinedpotential differences in initial responses comparing cognitiveversus procedural domains as well as comparing pediatricversus adult domains (Bonferroni corrected nonparametricWilcoxon rank-sum tests looking for a difference in the distribution of responses). Statistical significance was set at P 0.05.MATERIALS AND METHODSTwenty-eight of 32 expert members (88% response rate)responded to and participated in voting rounds (Table 1).Seventy-eight (72%) cognitive and 63 (75%) proceduralA list of cognitive and procedural learning objectives pertinent to spine surgery fellowship was generated by a reviewSpineRESULTSwww.spinejournal.com531Copyright 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.