AUSTRALASIAN FACULTY OF MUSCULOSKELETAL MEDICINE

TRANING MANUAL

For admission as a

Fellow of the Australasian Faculty of Musculoskeletal Medicine

CONTENTS BACKGROUND OF THE AFMM...........................................................................4

What is the AFMM?...........................................................................................4 What is a Fellow of the AFMM?.........................................................................5

THE SYLLABUS OF THE AFMM..........................................................................7 TRAINING.............................................................................................................8

Administration....................................................................................................8 1. The Board of Censors................................................................................8 2. The Director of Training .............................................................................8 3. The Supervisor ..........................................................................................9 4. The Mentor ..............................................................................................10 5. The Instructor...........................................................................................10

Training Program.............................................................................................10 Part 1 ...........................................................................................................11 Part 2 ...........................................................................................................11

Objective Assessment of Training ...................................................................12 1. Supervisors’ reports.................................................................................12 2. Log of Clinical Proficiency........................................................................13 3. QA Audit Forms .......................................................................................13 4. The Faculty Examination .........................................................................13

FACULTY EXAMINATION..................................................................................13 Application to Sit the Clinical Examination ......................................................13 Fees ................................................................................................................13 Locations and Dates of Examinations .............................................................13 Format of the Examination ..............................................................................14

Written Examination.....................................................................................14 Clinical Examination ....................................................................................16

CLINICAL PLACEMENTS ..................................................................................17 General Requirements ....................................................................................17 Formal Teaching Program...............................................................................17 Access to Resources.......................................................................................17 Clinical Supervision .........................................................................................17 Educational Supervision..................................................................................18 Design of a Training Program..........................................................................18 Educational Aids..............................................................................................18 Training Sites ..................................................................................................18 Retrospective Accreditation without Prospective Approval..............................19

REGISTRATION AS A TRAINEE .......................................................................19 Standard Requirements .................................... Error! Bookmark not defined. Failure to Register ...........................................................................................19 Continuation of Registration .............................. Error! Bookmark not defined. Overseas Training Doctors..............................................................................19

TRAINING PROTOCOL......................................................................................19 Approval of Training .......................................... Error! Bookmark not defined. Training Considerations .................................... Error! Bookmark not defined.

Interrupted Training .....................................................................................19 Leave from Training.....................................................................................19

Part-Time Training .......................................................................................20 Research during Training.............................................................................20 Teaching......................................................................................................20 Rural Training ..............................................................................................20 Transfers between Supervisors ...................................................................20

ADMINISTRATIVE REQUIREMENTS ................................................................21 1. Application to Train......................................................................................21 2. Supervisors’ Reports ...................................................................................21

WHEN A PROBLEM ARISES.............................................................................21 Disputes ..........................................................................................................21 Dispute Protocol ..............................................................................................21

First Actions .................................................................................................21 Further Resolution .......................................................................................21 Independent Review of Disputes .................................................................21 Appeals Process..........................................................................................22

Unsatisfactory Supervisor's Report .................................................................22 Independent Review of Adverse Report ......................................................22 Appeals Process..........................................................................................22

BACKGROUND OF THE AFMM What is the AFMM? The Australasian Faculty of Musculoskeletal Medicine is an incorporated body, registered in all States and territories of Australia and New Zealand. It is administrated by an elected Council as described in Article 28 of the Faculty’s Articles of Association. Elections are held biannually as determined by the Article 37 Faculty’s Articles of Association. It was constituted in 1993 and formally incorporated in 1995, as a result of negotiations between the Australian Association of Musculoskeletal Medicine and the New Zealand Association of Musculoskeletal Medicine. The inception of formal postgraduate courses in Musculoskeletal Medicine in three Australasian universities (Otago, Flinders and Newcastle) led the two national associations to believe that a separate and independent body was required to develop and promulgate standards of practice in the discipline based on a responsible, academic analysis of the scientific literature. Before the Faculty’s incorporation, various groups, including musculoskeletal physicians, rheumatologists, neurologists, rehabilitation physicians, interventional radiologists, anaesthetists and pain medicine specialists, had moved towards those ends but each from a relatively narrow perspective. The main intention of the Faculty was to co-ordinate the development of the scientific, academic and educational aspects of musculoskeletal pain medicine. The chosen means of achieving this aim was to draw together those involved in research and education in musculoskeletal pain medicine and those in specialist practice in the discipline to develop its scientific base and apply it to patient management. The Faculty was thus to bring together all doctors in Australia and New Zealand with similar aspirations to enhance co-operation towards the common goal of improving the quality of care for patients with musculoskeletal pain problems. In 1996 the Faculty was commissioned by the Australian Federal Minister of Health to conduct the National Musculoskeletal Medicine Initiative. This project involved the development of evidence-based clinical practice guidelines for the management of acute musculoskeletal pain problems; the evaluation of the safety, efficacy and cost-effectiveness of evidence-based practice for these problems; and an audit of how these problems were managed in usual care. The clinical studies of the Initiative were completed in July 2000. A draft report was provided to the Commonwealth Department of Health and Aged Care in September 2000 and a final report in 2001. The guidelines developed for the management of acute musculoskeletal pain problems were submitted to be considered for endorsement by the National Health and Medical Research Council. The National Musculoskeletal Medicine Initiative enabled the Faculty to define evidence-based practice for acute musculoskeletal pain problems, and to document the competence of its members in this practice. In the course of the Initiative, members of the Faculty also compiled the evidence about the management of chronic musculoskeletal pain problems. Since chronic pain was not encompassed by the Initiative, this other material has been and will continue to be published separately, in the form of books, chapters to books, and journal papers. Furthermore, members of the Faculty have otherwise been engaged in formal research studies concerning the reliability and validity of diagnostic procedures and the efficacy of therapeutic procedures for chronic pain problems. The main objectives for which the Faculty was established were to promote the science of, and education in, musculoskeletal pain medicine and to promote scientific methods of treatment of musculoskeletal disorders. In its early years the Faculty’s activities were entirely devoted to these objectives but, as time went on, the need arose for some form of recognition of expertise and competence in the field. Thus, for several years after its constitution, the Faculty entertained only Membership of the Faculty. It did not seek to examine, accredit, or otherwise recognise members until it had established an unambiguous knowledge base, standards of practice and a system of examination. Then, the Faculty deliberately eschewed the concept of ‘grandfathering’. Instead it determined that any recognition given should be based solely on

objective examination of a standard comparable to that of the learned Colleges. The Faculty offered Fellowship to practitioners who had demonstrated commitment to and expertise in Musculoskeletal Medicine by clinical practice and experience. A process was developed and a Board of Censors was appointed. The first examination was held in 1998. Those who passed the examination then, and subsequently, became Fellows of the Faculty. Of *** applicants, 54 have satisfied the standards required (see Examinations). The Fellowship has evolved as the academic arm of the Faculty. In 1999, the Medical Council of New Zealand recommended to Government that Musculoskeletal Medicine be recognised in New Zealand as a vocational branch (recognised discipline) of medicine. This was incorporated into the New Zealand Medical Practitioners Act in April 2000. Vocational registration requires both completion of the accreditation process of the New Zealand Association of Musculoskeletal Medicine and achievement of Fellowship of the Australasian Faculty of Musculoskeletal Medicine (AFMM). The Accident Compensation Corporation (ACC) of New Zealand has recognised those practitioners with both Vocational Registration in Musculoskeletal Medicine and Fellowship of the Faculty as specialist providers in Musculoskeletal Medicine. The Faculty has functioned from the outset as an educational institution. It achieves this by sponsoring scientific meetings, by continuing research, by education activities, and by training future Fellows. Having established a chapter of qualified Fellows, derived from those who had completed a graduate diploma in Musculoskeletal Medicine, or who held a Fellowship of another cognate Faculty or College, and who had practised in Musculoskeletal Medicine for a period of not less than five years, the Faculty devised a training program for the admission of future Fellows. This program is now recommended to those wishing to become accredited in the discipline. The Faculty currently has 54 Fellows as well as additional 105 Members. What is a Fellow of the AFMM? Fellows of the Australasian Faculty of Musculoskeletal Medicine are medical practitioners who:

• are registered in the Commonwealth of Australia or in the Dominion of New Zealand or in some other country, state or territory that has been approved by the Council;

• have appropriate clinical experience in the discipline;

• have undertaken further study of basic sciences pertinent to painful disorders of the musculoskeletal system, and the assessment and management of patients with such disorders, according to the principles of evidence-based medicine; and

• have demonstrated a specialist level of knowledge in this field by formal examination.

The training program is designed to produce Fellows with attributes:

• to determine and describe the mechanisms and causes of painful disorders of the musculoskeletal system and their associated symptoms and signs;

• to explain to patients, in understandable terms, the mechanisms and causes of painful disorders of the musculoskeletal system;

• to explain to their colleagues, of all ranks and disciplines, the mechanisms and causes of painful disorders of the musculoskeletal system;

• to assess comprehensively patients with acute and with chronic painful disorders of the musculoskeletal system, using techniques and procedures that are reliable and valid, according to the best available scientific evidence;

• to formulate a plan of management for patients with acute and with chronic painful disorders of the musculoskeletal system, using interventions known to be

safe, effective, and cost-effective, according to the best available scientific evidence;

• themselves to provide all or part of this management, according to their training, aptitude, and resources available to them, or

• by referral and collaboration, to secure and provide such appropriate management as they themselves may not be able immediately to offer;

• to evaluate critically the past, current and future literature pertaining to painful disorders of the musculoskeletal system;

• to advise both patients and their colleagues, including insurers and workers compensation authorities, on the nature and merits of various options available for the management of patients with painful disorders of the musculoskeletal system, and to distinguish those management options that are conjectural and evidence-based, and to distinguish those that a are reliable, valid, and effective from those that are not;

• to teach consumers, students, and colleagues any and all aspects of the basic and clinical sciences pertinent to the optimal management of painful disorders of the musculoskeletal system;

• to have an ongoing dedication to the evolution of the discipline by undertaking literature reviews and participating in research projects.

Because of their training and experience, Fellows are able to provide both for General Practitioners and for other members of the profession, a specialist resource that can secure for patients a comprehensive and valid assessment of their problems, and the most appropriate form of management that is safe, effective and cost-effective. Fellows have strong relationships with General Practitioners in securing optimal outcomes for the patients with musculoskeletal pain problems. Fellows in musculoskeletal pain medicine have trained and been examined in

• the anatomy and histology of the bones, muscles, joints, and nerves of the body;

• the biochemistry of fibrous connective tissues and their common disorders;

• the normal biomechanics of the musculoskeletal system;

• the physiology of nociception, and the behavioural dimensions of pain;

• the pathology of painful disorders of the musculoskeletal system, including valid and conjectural models;

• the principles of biostatistics and epidemiology as they pertain to evidence concerning the diagnosis and management of painful disorders of the musculoskeletal system;

• the application of these principles to actual clinical practice;

• obtaining a thorough history from patients;

• performing a physical examination of the musculoskeletal system, using any and all traditional techniques but with a consummate awareness of the reliability and validity of every technique;

• techniques available for the investigation of painful disorders of the musculoskeletal system, with consummate awareness of their reliability and validity;

• the management of pain and of patients with musculoskeletal pain, using explanation, education, encouragement and reassurance, activity, exercises, manual therapy, drug therapy, injections, appliances and other devices,

according to the best available evidence of safety, efficacy, and cost-effectiveness.

The particulars of this knowledge and skills, and the literature upon which they are based are recorded in detail in the Syllabus of the Faculty. Fellows in Musculoskeletal Medicine differ from other specialists related to this discipline in that, whereas others have been trained in particular disorders or in particular approaches to management, Fellows in Musculoskeletal Medicine are trained and examined in:

• knowledge explicitly pertinent to the pain and associated features suffered by patients with musculoskeletal disorders, often if not usually, not associated with overt or demonstrable pathology;

• knowledge and techniques pertaining to disorders suffered by patients that are not explicitly or formally embraced by the curricula of other specialists, or examined by those respective Colleges or Faculties;

• knowledge firmly based on contemporary evidence of reliability, validity, safety, efficacy, and cost-effectiveness, as opposed to traditional wisdom and past conventional practice.

• practices that have been subjected to independent scrutiny and evaluation, and which have been shown to be safe, effective and cost-effective, and shown to be not only appreciated but valued by consumers.

• practices that are based on sound ethical principles such that trainees develop respect for patients and the profession.

THE SYLLABUS OF THE AFMM As musculoskeletal pain medicine is a branch of medical science concerned with the functions and disorders of the musculoskeletal system, including the muscles, aponeuroses, joints and bones of the axial and appendicular skeletons and those parts of the nervous system associated with them, the Syllabus reflects such required knowledge. The Faculty has produced a comprehensive and fully referenced syllabus pertaining to musculoskeletal pain medicine. The objectives of the faculty’s syllabus are to outline the body of knowledge necessary for musculoskeletal pain physicians and other medical practitioners necessary to achieve expertise in the management of musculoskeletal pain disorders. Trainees will be examined in all aspects of the Syllabus. The requirements of the Board of Censors are underwritten in the Syllabus. The specific objectives of the Syllabus are each complemented with references to the available literature. For the most part these references constitute the key scientific publications that make up the evidence-base pertaining to the Specific Objective at hand. However, in some instances references are provided to prominent or influential publications, not because of any evidence they provide but to expose trainees to the broad diversity of views that obtain in some areas of musculoskeletal pain medicine. While not endorsing the views expressed in such publications, the Faculty considers that trainees and Fellows should be conversant with this literature especially when it competes with an evidence-based approach to the issue covered by the Specific Objective.

TRAINING The purpose of training in musculoskeletal pain medicine is to produce competence in managing musculoskeletal pain problems at the specialist level. Trainees are required to complete a specified program of training and examination in order to be eligible for admission to Fellowship of the Faculty under Articles 49,50,51and 52 of the Articles of Association of the Faculty. Trainees will be eligible for admission as members of the Faculty in accordance with the Articles of Association. Administration 1. The Board of Censors

The Board of Censors is the body charged with the supervision of the training program. The Board of Censors is presided over by the Censor-in-Chief, whose duties are described in Article 35.2 of the Faculty’s Articles of Association as follows:

a) To maintain the academic standards of the Faculty; and

b) To encourage the highest levels of scientific knowledge and practical competence in the discipline of musculoskeletal medicine; and

c) To apply the criteria established by the Council for the assessment of applicants seeking election to the Fellowship of the Faculty; and

d) To supervise the examination of candidates seeking election to the Fellowship of the Faculty and to report the results of such examinations to the Council; and

e) To preside over the Board of Censors.

The Board of Censors’ functions are described in Article 44 of the Faculty’s Articles of Association as follows:

“… to examine candidates seeking election to Fellowship of the Faculty upon

examination and to report the results of such examinations to the Council and to

perform and carry out such other functions as may from time to time be required by

the Council to be carried out by the Board.”

2. The Director of Training

The Director of Training (DOT) is the conduit between the Board of Censors and the training program itself. The DOT’s broad duties are to administer the training program. The DOT is ultimate responsibility for trainees and the training program. The DOT can be a member of the Board of Censors. The DOT can appoint other members to assist in his or her task. These appointees are called Associates of the Director of Training (ADOT). The DOT ensures that training occurs satisfactorily, with transition from rotation to rotation, and from year to year, with success at the Examination being the ultimate goal.

Duties The duties of the DOT include the following:

Development of a Training Program for Trainees • Formulation of the general program of educational activities; • Assistance in the development of appropriate supervised positions for

trainees.

Selection of Trainees • Identification and counselling of doctors who are considering

musculoskeletal medicine training; • Involvement in the selection process.

Training and Examination • Organisation of regular meetings with basic physician trainees. This is

particularly important at the beginning of each year when matters such as the feedback and grievance mechanisms should be specified. The meetings may be carried out by the DOT personally (by electronic means if necessary);

• Monitoring the progress of individual trainees, giving feedback and advice where appropriate;

• Liaison with mentors re such progress; • Review of examination results with individual trainees, including, if

necessary, facilitating counselling of failed candidates; • Discussing training options with individual trainees.

Other Responsibilities Relating to Training • Attending twice yearly meetings with the Board of Censors regarding the

training program; • Ensuring that the supervisor continues to meet the College standards of

accreditation; • Assisting with preparation of documentation for and scheduling of re-

accreditation site visits; • Assisting senior trainees with trial written and clinical examinations; • Accreditation of a clinic for training requires that full support be given to the

DOT and the training program – if this support is not provided, accreditation status will be jeopardised.

3. The Supervisor

The Faculty believes that a comprehensive training program is essential for the formation of the attitudes and skills required for the development of competent musculoskeletal pain consultants. During training the DOT has primary responsibility for nurturing and guiding individual trainees and has full support from the Faculty in this role. It is expected that an accredited supervisor will provide an appropriate environment for training and adequate support for the training program, including administrative support for the DOT and sufficient time to perform the duties expected of a supervisor. Usually this will

be provided for in a minimum of two sessions a week although this will vary depending on the number of trainees. Good trainees provide good clinical service ensuring that clinics receive an appropriate return for this expenditure. A fundamental principle of training is that it is carried out under supervision. The supervisor’s role is to ensure the trainee undertakes the training required by the Faculty. The supervisor for each year will normally be one of the physicians to whom the trainee is attached and should have a close working relationship with the trainee for the period of the rotation. Usually, a trainee will have one supervisor for each rotation. If a rotation involves attendance at more than one unit, additional supervisors should be nominated. The Faculty organises workshops for supervisors of trainees to assist them in their role. The primary role of the supervisor is to develop the trainee’s clinical skills to the level necessary for function as a musculoskeletal pain medicine consultant. The supervisor will provide formative assessment (feedback on performance). In order to do this, the supervisor will

o have regular meetings with the trainee, o observe the trainee's history taking, and physical examination, o discuss with the trainee interpretation of clinical findings, o assess the trainee's clinical evaluation of investigative procedures o discuss care plans to ensure they are appropriate to the needs of the patient and

carer. The supervisor will also provide summative assessment (formal determination of competence) to the DOT at the end of each rotation.

4. The Mentor The mentor acts in an administrative/pastoral role. They are generally less involved directly but are responsible for:

o checking that the trainee is working their way through the program; o checking that the trainee is covering the curriculum; o checking that supervision is adequate.

The mentor will have an important role if a trainee is having difficulties in the training program with the supervisor, or if supervision is inadequate or does not satisfy the requirements. The mentor should be a person who has empathy with the trainee. If a trainee has concerns the mentor should try to resolve them with the trainee but may need to take them up with the supervisor or the DOT. Supervisors and mentors have separate roles in the trainee’s scheme of training. Fellows acting in these roles should liaise with one another and strive to develop a co-operative relationship. A Fellow could be both a supervisor for one (or more) trainee(s) and a mentor for other(s).

5. The Instructor Instructors provides instruction but are not responsible for supervision.

Training Program

The training program consists of two parts. Part 1 training involves formal academic study of musculoskeletal medicine to the level of a Graduate Diploma in Musculoskeletal Medicine. Part 2 training involves clinical training under the supervision of Fellows accredited in the discipline and formal study of pain medicine according to the curriculum of one of the approved courses offered by universities for the award of the degree of Master of Pain Medicine.

The elements of the training program are described below.

Part 1

Graduate Diploma in Musculoskeletal Medicine

1. Prior to admission to the clinical training program, an intending trainee should undertake study of theoretical aspects of musculoskeletal pain medicine and complete the requirements of one of the approved courses offered by universities in Australia and New Zealand for the award of a Graduate Diploma in Musculoskeletal Medicine. Attainment of this diploma will qualify the intending trainee for admission to the Faculty as a Member, as set out in the Articles of Association. Courses suitable for this preliminary training will be those accredited by the Faculty from time to time. Intending trainees should consult the Board of Censors for advice about courses that meet the requirements.

or,

2. The Board of Censors may at its discretion give credit to an intending trainee

who, in lieu of a Graduate Diploma in Musculoskeletal Medicine, has attained Fellowship or other suitable qualification in a cognate field or has made contributions to research and the scientific medical literature in musculoskeletal medicine of such merit as to be recognised and approved by the Council as having special standing in the discipline (as described in Article 3.3 of the Faculty’s Articles of Association).

Part 2

1. Clinical Training Course A four-year course of clinical training is provided for trainees to enable them to gain knowledge of each of the areas of clinical practice encompassed by the discipline of musculoskeletal pain medicine and to become proficient in associated practical procedures. As they progress through this course, trainees will undertake rotations through accredited training positions in which they will have opportunities to refine knowledge of all aspects of musculoskeletal pain medicine, as defined by the Syllabus of the Faculty, and professional skills in communication, assessment, formulating plans of management and applying particular interventions. Each trainee will rotate through positions providing clinical training in various elements of musculoskeletal pain medicine (“core training positions”) and will also have opportunities to take positions providing more intensive training in aspects of musculoskeletal pain medicine or enable the trainee to gain experience of allied disciplines (“elective training positions”). Core training positions include attachment to hospital departments or individual practices of Fellows with appropriate turnovers of appropriate patients. A minimum of 6 of the 16 quarterly rotations must be in a core rotation. In these positions trainees have opportunities to develop proficiency in communication and professional skills pertinent to the skills required of a musculoskeletal pain physician as described above. Training involves exposure to acute and chronic conditions of each of the regions of the musculoskeletal system.

Elective training positions will include attachment to hospital departments or individual practices of Fellows or other accredited practitioners with particular interests in aspects of musculoskeletal pain medicine or cognate disciplines, allowing trainees to gain additional experience in areas such as musculoskeletal radiology and fluoroscopically-guided interventions. During training, a maximum of 10 quarterly periods can be allocated to these positions. Examples of such rotations include:

• Musculoskeletal radiology; • Orthopaedics; • Rehabilitation medicine; • Multidisciplinary pain clinic; • Headache clinic.

Elective training can also include further education in specific areas. Such a course needs to be accredited by the DOT. In general, such education must be closely aligned with the eventual role as a musculoskeletal pain physician. An example of such education is the successful completion of the Diploma of Fluoroscopic Pain Procedures.

2. Masters in Pain Medicine During the Part 2 training period, each trainee is required to undertake study of theoretical aspects of pain medicine and complete the requirements of one of the courses offered by universities in Australia and New Zealand for the award of the degree of Master of Pain Medicine. Courses suitable for this part of the training program are those accredited by the Faculty from time to time. Trainees should consult the Board of Censors for advice about courses that meet the requirements.

3. Participation in Quality Assurance Program During their Part 2 training, trainees are required to participate in the Faculty’s quality assurance program.

4. Part 2 Examinations Eligible trainees will be invited to undertake the Part 2 examinations, which include

o a written examination, and o a clinical examination .

Objective Assessment of Training Instruments used to provide objective evidence of training will include supervisors’ reports, a log of the trainee’s clinical proficiency, the trainee’s quality assurance audit forms and the results of formal Faculty examinations, as well as the attainment of the degree of Master of Pain Medicine.

1. Supervisors’ reports At the end of each training period the supervisor shall send the Board of Censors a report on the trainee’s performance during that period. The report should be reviewed and countersigned by the mentor and a copy shall be forwarded to the trainee.

2. Log of Clinical Proficiency The trainee will be expected to keep appropriate clinical records of patients seen during each training rotation and to present them to the supervisor upon request. At the completion of each three-month rotation the trainee shall submit a sample of ten case reports that demonstrate their competence/proficiency in the domains addressed during that training period (assessment, diagnostic formulation etc.). These reports may, depending on the nature of the training, include letters written by the trainee back to referring doctors, other reports and the trainee’s observations of, and comments about, procedures undertaken in musculoskeletal pain management. 3. QA Audit Forms Trainees will participate in the Faculty’s quality assurance program during their training and will provide the usual audit documentation each year. They will be required to audit a different area of musculoskeletal practice each year.

4. The Faculty Examination The Examination will test knowledge of the Faculty’s syllabus of musculoskeletal pain medicine and comprises both written and clinical assessments. It encompasses all components of the field, including basic sciences. Candidates must satisfy the Board of Censors in both Written and Clinical Examinations.

FACULTY EXAMINATION The Written Examination may be attempted after completion of the training program or earlier at the discretion of the Board of Censors.. The Board of Censors will determine eligibility for the Written Exam. The content of training undertaken must be specified in the application form to register for examination. The Board of Censors will verify each year of training. Applications for the Written Examination close on 1st August each year. Application to Sit the Clinical Examination Those who have been successful at the Written Examination are required to sit the next available Clinical Examination held by the College, unless approval of a deferment is granted. Applications for the Clinical Examination close on 15th October each year and under no circumstances will applications be received after this date. Fees A fee is payable at the time of application for the Written Examination. An additional fee is payable for each attempt at the Clinical Examination. Locations and Dates of Examinations The dates of the examinations are decided a year in advance. The Written Examination is usually held on the first Saturday in October in major Australian and New Zealand cities. The Clinical Examination is held in November/December in various centres in Australia and New Zealand. A supplementary Clinical Examination, if required, is held in February/March.

Specific dates for the Written Examination and Clinical Examination each year are available from the Board of Censors, and is published on the faculty website. Format of the Examination Written Examination

The Written Examination in musculoskeletal medicine consists of two multiple-choice papers.

Basic Sciences (1.5 hours)

The examination consists of 50 multiple choice questions. These questions test the knowledge of principles of medicine and basic sciences applicable to musculoskeletal medicine. The time allowed is 1.5 hours (after 10 minutes of reading time).

Clinical Applications (2 hours) The examination consists of 75 multiple choice questions. These questions assess investigational material and test the knowledge of the practice of musculoskeletal medicine and therapeutics. The time allowed is 2 hours (after 10 minutes of reading time).

There are three types of questions used in these examinations, designated types A, B and X. These are as follows:

Type A: Each consists of a stem and five options to make the stem into a complete statement. Any of the five options may be correct but only one constitutes the best option. Candidates mark “T” on the response sheet under the letter corresponding to the best option in each case and leave the other options unmarked. One mark is awarded for each question answered correctly. Questions answered incorrectly will score zero. No marks will be deducted from a candidate’s total score for wrong responses to these type A questions. Examples of Type A:

1. For the treatment of patello-femoral pain syndrome, the treatment for which there is the strongest evidence for efficacy is: A: analgesics B: NSAIDs C: strapping (according to the McConnell method) D: exercise E: lateral retinacular release Key: D. (ref. NMMI Guidelines Appendix KA.10: Tendon Impairment.)

2. In the lumbar spine, resistance to anterior sagittal rotation is best provided by the:

A. intervertebral discs B. capsules of the zygapophysial joints C. supraspinous ligaments D. interspinous ligaments

E. ligamentum flavum Key: B. The zygapophysial joint capsule is responsible for 39% of the resistance to anterior sagittal rotation, the disc 29%, the supraspinous and interspinous ligaments 19%, and the ligamentum flavum 13%. (ref. Bogduk: Clinical Anatomy of the Lumbar Spine and Pelvis).

Type B: Each consists of a primary statement and a secondary statement that may or may not be causally related. Candidates mark “T” on the response sheet under the letter corresponding to the best option in each case, as follows:

• under A if both statements are correct and they are causally related • under B if both statements are correct but they are not causally related • under C if the first statement is correct but the second statement is

incorrect • under D if the first statement is incorrect but the second statement is

correct • under E if both statements are incorrect.

Other options should be left unmarked. One mark will be awarded for each question answered correctly. Questions answered incorrectly will score zero. No marks will be deducted from a candidate’s total score for wrong responses to these type B questions. An example of Type B:

There is no evidence to support the use of injection of corticosteroids in the treatment of De Quervains tenosynovitis

because Histopathological studies have shown that in De Quervains tenosynovitis there is an absence of inflammatory changes.

Key: S=F, R=T. There is one prospective class III-3 study which demonstrates significant benefit in patients with De Quervain’s tenosynovitis treated with steroid injection. Histopathological studies have shown that the pathological process in this condition is fibroproliferative rather than inflammatory. In fact, inflammatory changes are conspicuous by their absence. (Ref. NMMI Guidelines Appendix WR.10: Tendon Impairment.)

Type X: Each consists of a stem and four options that lead on from it. Each option will be either true or false with respect to the stem. Candidates mark “T” on the response sheet under the letter corresponding to each true option and “F” on the response sheet under the letter corresponding to each false option. Options about which candidates are unsure can be left unmarked. The four responses to each stem will be considered as a set and a maximum of one mark is available for each question. In assessing responses, options correctly designated “T” or “F” will score one quarter of a mark and options incorrectly designated “T” or “F” will lose one quarter of a mark. Thus three correct responses and one incorrect response will score three quarters minus one quarter = half a mark for the question overall. Two or more incorrect responses will cancel out other correct responses and result in a score of zero for the question. No penalties will be incurred for responses left unmarked so two responses correctly designated and two left

unmarked will attract a score of half a mark for the question. The minimum score for each type X question is zero and no penalty will be carried over from one question to others to affect a candidate’s total score. An example of Type X:

Ulna nerve compromise at the wrist produces the following clinical signs: A. Fixed flexion of the PIP joint of the ring and little fingers B. Fixed flexion of the DIP joints of the ring and little fingers C. Wasting of the 1st dorsal webspace of the hand D. Flexion of the thumb IP joint as patient attempts to resist withdrawal of a piece

of paper being held between the thumbs and side of index fingers E. Weakness of hand ulna deviation. Key : A=T (ref. McRae: Clinical Orthopaedic Examination. 4th Ed. pp 21-23) Explanation:-Ulna nerve lesion at the wrist may lead to the typical claw hand with flexion of the PIP joints of the ring and little fingers due to paralysis of the ulna 2 lumbricals. B=F If the DIP joints are also flexed then this suggests that the flexor digitorum profundus is intact and the lesion is distally placed. C=T Because the ulna nerve supplies all of the interossei, interosseous muscle wasting occurs, with the 1st dorsal interosseous muscle usually the 1st to become apparent, with hollowing of the 1st dorsal web space. D=T Grasping a piece of paper between the thumb and side of the index finger requires thumb adduction by adductor pollicus, which is supplied by the ulna nerve. Paralysis of thumb adduction results in the trick movement of thumb flexion at the IP joint during this manoeuvre to compensate. Eponymously, this is known as Froment’s test. E=F The most powerful ulna deviator of the wrist is flexor carpi ulnaris, which derives its ulna nerve innervation well proximal to the wrist. Extensor carpi ulnaris also contributes, but is innervated by the posterior interosseous nerve.

Clinical Examination

The Clinical Examination is designed to test clinical skills, attitudes and interpersonal relationships. The examination format requires candidates to be examined on one long case. The standard required includes the breadth of knowledge, aptitude and skills sufficient for the management of patients with musculoskeletal pain to a consultant level.

Examination Results Written Examination: Results will be available from the Faculty office on a date to be specified by the Censor in Chief, but typically within four days after the examination date. Written notification of results will also be sent to all candidates. Clinical Examination: Results will be available from the Faculty office following completion of the marking process, typically within four days of the examination. Written notification of results will also be sent to all candidates Feedback Protocol for the Part 2 Clinical Examination Individual feedback is available, on request to the Board of Censors, to all candidates who are unsuccessful in the Part 2 clinical examination. Application must be made within fourteen days

of distribution of the results. CLINICAL PLACEMENTS General Requirements Clinical placement of a trainee shall be to an accredited clinical supervisor or supervisors with responsibility for patients in musculoskeletal pain medicine. Placements should be designed to develop a graded responsibility through each training year. Trainees should attend prescribed courses of study and tutorials directly related to the training program, usually around four hours per week of employed time. In the first two years of training such requirements will be largely met by the Masters of Pain Medicine. Formal Teaching Program Formal teaching should be organised and delivered by appropriately skilled and experienced staff, applying currently accepted educational principles to the teaching program. The structured educational program provided in a currently recognised educational format should be of sufficient duration to achieve the training objectives. Ideally, all trainees and trainers will receive a written copy of the general and formal teaching course objectives. It is recommended that this is a minimum of 120 hours per year (e.g. four hours per week for 30 weeks). Access to Resources To meet the objectives of the training program, the trainee requires access to general facilities and resources that include:

• a library, containing recognised texts and a relevant range of current journals, and with a computerised database (Medline). The Faculty’s library facility is located in the Fcaulty’s offices in Newcastle;

• facilities for teaching in a clinical setting; • facilities for meetings and teaching sessions; • a structured learning program; • audiovisual teaching equipment.

A broad range of clinical staff is expected to have input into the trainees' learning experience. Clinical Supervision Clinical supervision will come from a number of people through each year of the program. Each trainee will be assigned a clinical supervisor/s for each rotation. Clinical supervisors will usually have no more than two basic trainees under their supervision. The level of supervision of the trainee is dependent on ability and will vary as the trainee progresses through the program. Opportunities for directly supervised, indirectly supervised and monitored, and relatively independent clinical practice should be provided according to the ability of the trainee. As a guide, eight hours per week of direct trainee/supervisor clinical contact is expected, plus one hour of trainee/supervisor individual contact. The trainee is essentially apprenticed to the clinical supervisor. As well as the direct clinical responsibility carried by the specialist for the work of all members of the clinical team, the additional responsibilities of a clinical supervisor are:

• to review the training objectives for each placement with the trainee at the beginning of the placement, and objectively assess progress against these objectives at the end of each rotation;

• to create a suitable individual learning environment for the trainee; • to ensure that a wide range of opportunities for clinical skill development is available to

the trainee.

Educational Supervision Individual direct educational supervision provided by the supervisor will include:

• helping the trainee make effective use of the learning environment provided; • directing and focussing learning so the trainee develops self-directed training

techniques; • helping the trainee develop understanding of the wider aspects of vocational training.

In addition to direct educational supervision from current clinical supervisors, the overall educational supervision is directed by the DOT who reports directly to the Board of Censors. Design of a Training Program In order to design a training program, the trainee, the supervisor and the DOT must be familiar with:

• legislative requirements for vocational registration; • the general objectives of the training program; • the current stage of training of the particular trainee; • the requirements of each trainee to receive a comprehensive exposure to all aspects of

musculoskeletal pain medicine. The DOT and trainee first need to map out a program for the year in question. All proposed training programs must be approved by the DOT prior to each placement. Training will be under the direction of a supervisor, with guidance of a mentor. The DOT is responsible for ensuring that the supervisor and mentor are accredited, and that the education plan subsequently submitted by the trainee and supervisor is satisfactory, If the trainee is in the first year of training, the DOT will design a tentative overall plan for the full four years of training. In the second, third and fourth years of training, the training program should be amended to fill any deficiencies . The trainee should be encouraged to discuss the proposed training program, previous experiences and future expectations. Following the initial meeting, the trainee should complete the Application to Commence or Continue Training Program form and forward it to the Board of Censors for approval. The trainee and supervisor should keep a copy of the application form. A copy of the Supervisor's Report form will be sent to the trainee at the beginning of each training placement. This form is used to document the trainee's progress in each of the eight generic objectives of advanced training, and any specific vocational training requirements. The trainee should be aware that assessment will include all aspects of professional behaviour, including ethics and respect of patient’s rights The supervisor should discuss the form (and its implications) with the trainee. Educational Aids Trainees will be assisted by the educational resources of the Faculty and its members, including the Faculty’s library of published works, notes, videotapes, internet instruction and refresher courses. Training Sites

The Board of Censors and the DOT will determine the suitability of sites and training programs for each trainee.

Prospective Approval of Training The Faculty normally requires training to be approved prospectively. Retrospective endorsement is only considered in exceptional circumstances. In such circumstances, the Board of Censors has discretion to grant recognition of up to one year of previous training. Applications for retrospective endorsement can only be approved where the requirements of training have been met. In all instances appropriate supervisors' reports are required. Periods of less than three months will not be considered. REGISTRATION FOR PART 2 TRAINING Application Prospective trainees are required to lodge an Application to Register as a Part 2 Trainee form, and the prescribed fee, at the Faculty office. Determination of Application Successful applicants will be admitted to the training program and registered with the DOT. The Board of Censors reserves the right to determine any application at its unfettered discretion. All applicants will be advised of the Board’s decision in due course. Failure to Apply A person will not be recognised as a trainee if they have not applied for registration. Overseas Trained Doctors Overseas trained doctors will be eligible for the Faculty’s training program on the same basis as others, which includes registration as a medical practitioner in Australia or New Zealand.. TRAINING CONSIDERATIONS Interrupted Training

Normally training should be continuous. If a training program is interrupted for more than two years, the DOT may require an additional period of training.

Leave from Training

In each year of training, standard statutory recurrent leave entitlements (holiday, conference etc.) can be taken without prolonging training. However, it is recognised that over a four-year training period, additional or exceptional periods of leave may be required. Examples include maternity/paternity leave or prolonged illness. These may occur as a single episode or on repeated occasions. As a general principle, the total period of leave in any one training year should not exceed two months. Total leave taken during training will be considered and individual circumstances may be taken into account.

If the total period of leave during training is considered to have been in excess of the guidelines or to have interfered significantly with training, an additional period of training may be required.

Part-Time Training

Although it is strongly recommended that training be undertaken full-time, part-time training may be acceptable provided that the position is equivalent to 50% or more of full-time training, and that all the requirements of full-time training have been met. The total length of training, including both full-time and part-time, shall be equivalent to that required under full-time training (48 months). Work sharing is acceptable, particularly if the work is shared concurrently by two part- time trainees. Approval and accreditation processes are the same as for full-time training and fees payable to the College over the total period of advanced training will not normally exceed those of full-time training.

Research during Training

The Faculty has a flexible attitude to the inclusion of research in training. However, all applicants for Fellowship must be satisfactorily trained as Fellows whether or not their training program includes a significant component of research. At least three years of the four years training must be spent in clinical musculoskeletal pain medicine. Documentation must be provided.

Teaching

Trainees are expected to teach other health professionals in the course of their training. Teaching may include bedside tutorials, small group discussions and larger group presentations. Whilst some material will be well known to trainees, preparation will usually be required. When such are available, trainees are encouraged to attend courses outlining principles of adult learning and effective presentation techniques. Feedback from more senior clinicians should be arranged periodically.

Rural Training

The Faculty wishes to promote rural training. It realises that there is a shortage of instructors in rural Australia, and believes that rural posts offer excellent training and provide an opportunity for trainees to experience practice in a non-metropolitan setting.

Transfers between Supervisors Trainees are normally supervised by only one supervisor during any one rotation. Transfers from a supervisor may occur at short notice. In such instances trainees can not assume that the new component of training will be accredited.

At the Instigation of the Trainee If for some reason the trainee wishes to transfer from one supervisor he or she is required to lodge an application in writing to the DOT. Prior to this course of action it is expected that the process will involve discussion with the others including the mentor, the supervisor, and the DOT.

At the Instigation of the Supervisor Again, accreditation is not automatic, even if this occurs due to unforeseen circumstances.

ADMINISTRATIVE REQUIREMENTS There are two forms to be completed during each year of training. These are: 1. Application to Train The Application to Commence or Continue Training Program. This must be prepared before the training program commences each year. It is prepared by the trainee in conjunction with the envisaged supervisor, and submitted to the DOT. The DOT then determines whether or not the training program is suitable. The decision is conveyed in writing to the trainee and to the relevant supervisors. As each year consist of four rotations, it may not always be possible to complete the next year’s rotation application by the designated date. Reasons for delays must be specified in writing to the DOT. 2. Supervisors’ Reports This is completed by the Supervisor at the end of each rotation. It must be countersigned by the trainee, before copies are sent to the mentor and the DOT. Trainee are also given an opportunity to comment in a Trainee Survey form on various aspects of training including facilities for training; learning opportunities; supervision of training; and communication with the mentor and the DOT. This is not compulsory and accreditation is not dependent on submission of the forms. The Trainees are not required to discuss the surveys with their supervisors. The Faculty assures confidentiality of the forms and their content.

WHEN A PROBLEM ARISES

Disputes Trainees should discuss their progress with their mentor at intervals. Particular attention should be drawn to any issues about which there seem to be differences of opinion between the trainee and the supervisor, and to any other difficulties the trainee may have. In the case of disputes, the mentor and the supervisor should discuss the circumstances with explicit reference to the requirements of the training program. Dispute Protocol First Actions The first port of call for both the trainee and the supervisor is the Mentor. The responsibility of the Mentor is to act in the interests of the trainee in the first instance. In assessing disputes the Mentor shall use the rights of the patients and the syllabus as the guidelines for arbitration. The Mentor generally involves the DOT if the dispute is not easily resolved. If the dispute is not resolved to the satisfactorily to any party, the matter can be referred by the aggrieved party or parties to the Board of Censors. Further Resolution If the process is not settled by the above process, the aggrieved party/parties are required to formalise the process by informing the Secretary of the Faculty of the nature of the dispute, with a copies to other parties in the dispute. Independent Review of Disputes

When the aggrieved party or parties notifies the Secretary of the Faculty in writing of the dispute, the Board of Censors shall then be convened to deal with the dispute within 28 days. The Board of Censors shall adjudicate on the dispute without knowledge of the names of the aggrieved parties: names on any documents will be masked by the Secretary. The Board of Censors reserves the right to interview parties in order to reach a resolution. The Board of Censors shall report in writing to the aggrieved party/parties within a further 28 days. Appeals Process Aggrieved party/parties may appeal the Board of Censors’ determination to the Council within 28 days. Members of the Council, acting as an appeals committee, shall make the final determination. No member of Council who is also a member of the Board of Censors shall sit upon this committee. Unsatisfactory Supervisor's Report An adverse supervisor's report should only be submitted to the DOT after the process of problem identification and remediation at the hospital or training site has failed. If, after further discussion with the supervisor it is considered by the DOT that the period of assessment might be unsatisfactory, and process of independent review is undertaken. Independent Review of Adverse Report This involves interview by the DOT and one other Fellow, who may be a member of the Board of Censors, but not the Censor-in-Chief, of the trainee, the supervisor and any other relevant party. The purpose of the interview is to hear, in detail, assessments by the supervisor and other consultants of the trainee's performance and to learn (separately) the trainee's views about the year's experience and performance. Ideally specific problems are identified, and a remedial process is defined. The problem is communicated to the DOT, and decision is communicated to the trainee and the supervisor in question. This process may, for example, require a future supervisor to pay special attention to specific areas of performance and to report back to the DOT at regular intervals. The results of not satisfying the remedial process are also clearly communicated to the trainee. For example, the trainee may need to undertake additional training or may, under extreme circumstances, be dismissed from the training program. Appeals Process If this Independent Review results in a serious outcome for any party the opportunity for further appeal exists. This process involves application to the Council within 28 days of the unsatisfactory outcome. Members of the Council, acting as an appeals committee, shall make the final determination. No member of Council who has a role in the case shall sit upon this committee. ADMISSION AS A FELLOW Successful candidates will be admitted to Fellowship on completion of the training requirements to the satisfaction of the AFMM Board of Censors. Those admitted to the Fellowship may be referred to as "Musculoskeletal Pain Physicians".

FAFMM is not currently recognised by the HIC as a registrable specialist qualification in Australia.