Keywords translating - transcultural adaptation - medical education - surveys and questionnaires
Introduction
Musculoskeletal disorders, including lumbalgia, lumbosciatalgia, and arthrosis, are
frequent complaints in primary clinics, accounting for up to 25% of the reasons to
seek medical care. The World Health Organization declared the period from 2000 to
2010 as the Bone and Joints Decade , thus confirming the importance of this topic in medicine.
Therefore, it is essential to train adequately the professionals who will meet this
high demand. The development of skills in multiple care dimensions during the training
of orthopedists and traumatologists is paramount to assure the proper treatment of
patients. To do so, tools assessing the development of these skills are protagonists
both to encourage individuals to acquire abilities they still do not possess and to
provide data to improve the educational quality of residency programs.[1 ]
No instrument in Portuguese evaluates the teaching of musculoskeletal disorders throughout
medical training. However, similar questionnaires, available for several medical specialties,
have been created in other countries, including the Orthopedic Surgery Milestone Project.
This instrument evaluates physicians from residency or fellowship programs recognized
by the Accreditation Council for Graduate Medical Education (ACGME), a non-profit
private institution that assesses and endorses all graduate medical training programs,
including internships, residencies, fellowships, and subspecialty programs, in the
United States.[2 ]
The Orthopedic Surgery Milestone Project started in 2013 to evaluate the skills and
knowledge of residents from a specialty within the same set of competencies. It does
not replace existing assessments in residency programs but provides a common framework
to analyze acquired skills.[3 ] The Milestones instrument generates detailed information on the strengths and weaknesses
of each residency service and identifies syllabus gaps to be addressed, improving
the educational quality of residency programs.
The ACGME requires an annual evaluation, including systematic analysis of curriculum,
resident performance, faculty development, and program quality. It also suggests that
assessment instruments include written examinations, global ratings, and case/procedure
records. The teaching analysis model recommended by the ACGME is based on the skills
deemed fundamental for professional practice.
Residents are evaluated through milestones, that is, medical knowledge, patient care,
professionalism, communication skills, and system practice, in addition to learning
based on such practices and improvements. During the assessment, a preceptor selects
the milestone that best describes the resident's current performance, from levels
1 to 5. Level 1 represents the milestones expected from a 1st-year resident, and level
5 refers to the performance goals defined for the residency, potentially describing
the performance of a professional practicing for several years.[4 ] However, it is worth mentioning that these levels do not correspond to the year
of residency; moreover, the selection of a certain level implies that the resident
substantially demonstrates the characteristics related to it, as well as those from
lower levels. All residents, from the 1st to the last year of medical residency, will
be evaluated using the Milestones instrument.
Thus, the translation and transcultural adaptation of the Orthopedic Surgery Milestone
Project will help in the evaluation and, consequently, training of professionals specializing
in orthopedics.
Methods
After the ACGME authorized the translation of the questionnaire, two Brazilian translators
fluent in English performed the first translation into Portuguese, and both texts
were compared to formulate a consensus text. This text was back translated into English
by two bilingual translators whose main language is English and who had no knowledge
of the original text of the instrument. This translation was evaluated and compared
to the original text by a review committee to correct potential discrepancies and
enable the preparation of a pretest version of the questionnaire.
The last step consisted of evaluating the clarity and understanding of the questionnaire
regarding its intended use. Since the pretest version had the desired characteristics,
it was confirmed as the final text.
Results
[Figures 1 ]
[2 ]
[3 ]
[4 ] to [5 ] describe the translation into Portuguese and transcultural adaptation of the Milestones
2.0 instrument. It is noteworthy that the back translation process showed that the
initial Portuguese text corresponded to the English text, with no semantic divergence
between translators.
Fig. 1. Diagram of the protocol used for translation and transcultural adaptation of the
Milestones evaluation instrument.
Fig. 2 Translation of the Milestones instrument. Clinical case 1-original text.
Fig. 3 Translation of the Milestones instrument. Clinical case 2-original text.
Fig. 4 Translation of the Milestones instrument. Clinical case 3-original text.
Fig. 5 Translation of the Milestones instrument. Clinical case 4-original text.
The first two texts were the initial translations into Portuguese. Both presented
semantic similarity, with no modification of the analyzed proposition. However, sometimes,
different words with similar meanings were used to translate the same term (e.g.,
basic imaging exams versus basic imaging studies). A specialized committee reviewed
the two translations and reconciled them into a single, easier-to-understand text.
The final text consisted of the back translation of the reviewed versions.
The original Milestones instrument has 54 pages and 20 clinical situations from different
areas of orthopedics; its questions encompass the doctor-patient relationship, in
addition to theoretical and practical medical knowledge ([Table 1 ] and [Figures 1 ]–[2 ]).
Table 1
Original text
Initial text
Consensual text
Final text
Appropriately orders basic imaging studies
Solicita adequadamente os exames básicos de imagem
Solicita adequadamente os estudos básicos de imagem
Solicita adequadamente os estudos básicos de imagem
Provides procedure and patient specific postoperative management and rehabilitation
Fornece gerenciamento pós-operatório e reabilitação específicos para cada procedimento
e paciente
Fornece procedimentos e gerenciamento pós-operatório e reabilitação paciente – específicos
Fornece gerenciamento pós-operatório e reabilitação específicos para cada procedimento
e paciente
Prescribes and manages nonoperative treatment (e.g., nonsteroidal antiinflammatory
drugs [NSAIDs], steroid injections, brace, rocker bottom shoes)
Prescreve e gerencia o tratamento não cirúrgico (por exemplo, anti-inflamatórios não-esteroides
[AINEs], injeções de corticosteroides, imobilizadores, sapatos com a entressola curva)
Prescreve e gere o tratamento não cirúrgico (por exemplo, anti-inflamatórios não-esteroides
[AINEs], injeções de corticosteroides, órteses, calçado ortopédico com sola curva
(do inglês rocker bottom shoes )
Prescreve e gere o tratamento não cirúrgico (por exemplo, anti-inflamatórios não-esteroides
[AINEs], injeções de corticosteroides, órteses, calçado ortopédico com sola curva
(do inglês rocker bottom shoes )
Capable of surgical reduction and fixation of a full range of fractures and dislocations
Capaz de reduzir e fixar cirurgicamente uma gama completa de fraturas e luxações
Capaz de reduzir e fixar cirurgicamente uma série completa de fraturas e luxações
Capaz de reduzir e fixar cirurgicamente uma gama completa de fraturas e luxações
Performs surgical reduction and fixation of a simple fracture
Reduz cirurgicamente e fixa uma fratura simples
Realiza a redução cirúrgica e a fixação de uma fratura simples
Realiza a redução cirúrgica e a fixação de uma fratura simples
Discussion
There are no instruments to assess medical skills regarding musculoskeletal disorders
in Portuguese, but the Orthopedic Surgery Milestone Project fulfills this purpose
in English. The method of translation and transcultural adaptation used here was recommended
by Guillemin et al.[4 ] It consists of four stages: initial translation, back translation, elaboration of
a consensus text, and preparation of a commented pretest version and the final text.
The present study followed the guidelines recommended by Guillemin et al.[4 ] to minimize bias and biased results. This methodology makes the translated Milestones
questionnaire suitable for application in Brazilian orthopedic residency services
to assess the skills and abilities of these professionals.
Translation and adaptation of this instrument occurred after ACGME approval. The entire
process was carried out properly, following the standards of cultural adaptation,
and there were no difficulties in understanding any question. The Milestones instrument
is widely recognized and used in the United States in different medical services and
subspecialties, including clinical and surgical areas (e.g., Milestones for Plastic
Surgery, Internal Medicine, Urology). It is applied easily through clinical situations
that assess professionalism, communication skills, and medical knowledge. Residents
are analyzed and graded on competency scales and developmental milestones throughout
the year. It is a way for the student to recognize their limitations and deficiencies
and improve them. The goal is to make specialist training programs more adequate to
the current demand so that the specialized physician can work in public and private
sectors, either in large or small centers.[5 ]
A study based on competencies and milestones aims to identify and analyze any deficiency
in the training process of resident physicians, allowing preceptors to reinforce the
teaching/learning of that competency.[6 ] In addition, competency-based training allows for more uniform curricular development
in medical residency schools.
The adaptation of this assessment instrument to the Brazilian context required minor
grammatical and cultural adjustments. In preparing the pretest version and the final
text, we tried to maintain the form that most closely resembled the original to achieve
equivalent semantics between them.
It is also worth mentioning that no items from the original questionnaire were included
or excluded throughout the development of the final text, preventing further changes
in psychometric properties to allow texts comparison.
The potential use of Milestones as a method for evaluation and improvement of the
quality of teaching in medical residency services will result in physicians better
prepared to exercise their profession. The translation of this instrument and its
application will allow the assessment of the main deficiencies in Brazilian Orthopedic
Services, which may improve medical education.
The Portuguese version of the Milestones instrument, adapted to the Brazilian culture,
is applied easily.
This instrument should be used once a year in residents of the 3 years, similar to
the Assessment Test of Residents in Orthopedics (TARO) by the Brazilian Society of
Orthopedics (SBOT). We initially propose the assessment of competency 1 in the 1st
year of residency, competencies 2 and 3 in the 2nd year, and competencies 4 and 5
in the 3rd year of residency. However, instrument application will eventually determine
the equivalence. The final text of this questionnaire was the result of the corrections
made by all translators and review teams involved. Although there is no evidence against
the adequate translation and transcultural adaptation of the Milestones instrument
to Brazil, future studies will establish the accuracy and reliability of this tool
in Brazilian orthopedic and traumatology residency programs.
Conclusion
The translation into Portuguese and the transcultural adaptation of The Orthopedic
Surgery Milestone Project provide an instrument for assessing competencies suited
to the Brazilian reality. This instrument can evaluate different aspects of knowledge
and practice over the 3 years of specialization, seeking a better medical education.
The translation of the Milestones assessment instrument into Portuguese was consistent
with the original texts.
