Competency Framework for Podiatric Medicine Training: A Validation Report Based on an Adapted E-Delphi Across Canada

OBJECTIVES Competency-based medical education has been introduced into many health professional curricula. Based on CanMEDs, a framework has recently been developed for podiatric medicine education in Canada. This study aimed to validate the framework through a consensus of various podiatric medicine experts across Canada. METHODS An adapted Delphi method was used for content validation. Two structured online questionnaires were used to gather expert opinions and agreement on the roles and core competencies described in the framework previously developed. The validation consensus threshold was set at a minimum of 80% agreement. The summary of comments and suggestions was used to reformulate certain items after the research team reached a consensus. RESULTS Out of the 51 experts invited from the Canadian Podiatric Medicine Association, 19 completed the first-round questionnaire (mean podiatric experience = 24.5 years; standard deviation 17.6). After the first round, “Podiatric Expert”, “Communicator” and “Scholar” roles have been modified. After these modifications, a consensus was obtained at the second round completed by 13 experts. Overall, 95% of the experts agreed that the competency framework was relevant even if some indicators would need to be adapted to suit the requirements of each province and territory. CONCLUSION This validated framework supports the excellence and the quality of our podiatric educational program. It also promotes the adoption of a uniform education of podiatrists in Canada and worldwide.


Background
3][4] It is postulated that it increases the quality and safety of healthcare by developing an educational system centered on the learner, which would contribute to the development of a healthcare system centered on the patient. 1 This model can also enhance the clinical performance of health care providers. 5his approach was recently explored for podiatric medicine education using a modified Delphi method at our university. 6his resulted in the development of competency-based podiatric medicine education using the CanMEDS, a competency framework based on the work initiated by The Royal College of Physicians and Surgeons of Canada, 7 which included seven roles (ie, podiatric expert, collaborator, communicator, health advocate, leader and manager, professional and scholar), 24 core competencies and 288 observable-related indicators. 6ntent validation by external experts is an important step before implementation following knowledge product developed by a Delphi technique, 8 particularly for the dissemination of our work across Canada or worldwide to improve the quality of podiatric medical education. 6Various methods (eg, Delphi technique and nominal group technique) for the validation of frameworks in medical education research exist, but these are poorly standardized. 9Therefore, our objective was to seek out consensus among podiatric medicine stakeholders across Canada in order to obtain controlled feedback to validate and enhance our framework.Journal of Medical Education and Curricular Development online Delphi technique (e-Delphi) 10 as this eliminated the constraints of geographic location, and facilitated the organization and analysis of the data collected. 9,11,12This study is reported using CREDES (Conducting and REporting DElphi Studies) criteria, 8 which promotes consistency and design reproducibility.Participation was voluntary, ethics approval was waived by the Institutional Review Board (Comité éthique de recherche avec les êtres humains of Université du Québec à Trois-Rivières) and the project respected the Tri-Council Policy Statement of Canada (in accordance with the Declaration of Helsinki). 13Electronic informed consent was obtained from the experts at the beginning of the questionnaire and the entire process was anonymous.

Participants and recruitment
As it has been shown in previous studies that large panels generate low response rates and that more than 30 participants rarely improve results, the convenience sample size was estimated at between 12 and 24 experts; this was also to reduce the influence of rater aberration in the content validation task. 14,15Inclusion criteria were: 1) ability to read, understand and write in English; 2) obtained a diploma or degree related to podiatry/chiropody in Canada; 3) practice exclusively in Canada.The Canadian Podiatric Medical Association (CPMA) (JA) supported the experts' identification, and the recruitment within their network by targeted podiatrists involved in continued education and profession development in Canada.For this validation study, an expert in podiatric medicine was someone who met our inclusion criteria.Potential participants were solicited by email from October to December 2022, with a detailed description of the study, the published framework, and the online questionnaire.

Data collection and e-Delphi rounds
The team (VB, JH, OH) constructed a questionnaire using Qualtrics software (Qualtrics software, Provo, UT), knowledge user's input (JH, YA) and methodology expert (MB).This is not a validated questionnaire (Supplementary Appendix A).The questionnaire consisted of three sections: 1) participants' characteristics; 2) level of agreement regarding the roles and core competencies using a 7-point Likert scale (1 [strongly disagree] to 7 [strongly agree]); and 3) general comments about the indicators or suggestions including the feasibility of implementation. 14Three rounds were expected for the e-Delphi process (Figure 1), detailed in Appendix B. The agreement threshold was set at 80% by the team as there is no standard. 14For each round, two reminders were sent to the participants to obtain the highest possible response rate and a two-week deadline was given to complete the questionnaire.

Data analysis
Data analysis was performed using Qualtrics software (Qualtrics, Provo, UT) with descriptive statistics.A narrative synthesis was produced for the written content, which was evaluated by two researchers (VB, OH) and discussed with the entire team as necessary to move along the process.

Results
The characteristics of the experts involved in this validation study are presented in Table 1.Most of the panel of experts were men practicing in the central region (ie, Québec or Ontario) who had a doctorate in podiatric medicine, which is the same degree as those who developed the initial framework.However, the majority had a surgical residency, which was not the case in the development phase. 6The mean experience in podiatric medicine of the panel was approximately 25 years.
The response rate was 37% (19/51 invited participants) for the first round and 68% (13/19) for the second round (Table 1).As consensus was reached at the end of Round 2, the third round was unnecessary.As a result of this content validation (Table 2), the description of "Podiatric Expert" was slightly modified, along with a competency for this role.No changes were made to the "Collaborator", "Health Advocate", "Leader and Manager", and "Professional" roles.Two competencies have been modified for the "Communicator" role, and a new indicator has been added to a competency under the "Scholar" role.The experts agreed (95%) that this framework could be relevant to continuing medical education even if some indicators may need adaptation across the provinces and territories.

Discussion
7][18] This validation has contributed to modifying the initial competency framework, taking into account expertise across Canada. 6This framework was presented to the experts who developed the initial framework, and this version will be implemented.The iterations supported medical reasoning to the "Podiatric Expert" and the "Scholar", care trajectory to the "Podiatric Expert" and ethical consideration to the "Communicator" roles which are all in alignment with care quality and the Quintuple Aims. 19he expert panel was balanced geographically.However, as there were few podiatrists in the northern regions, we were unable to represent these areas.The experts solicited had more experience (25 years vs 18 years) and were more surgically trained (47% vs 37%) than at our institution. 6This is consistent with the fact that podiatrists outside Québec are often trained in English-speaking countries, mostly in the United States requiring residency, and Québec does not offer a residency program. 20ome provinces, particularly in the Western regions, require a surgical residency to practice or to perform certain procedures. 21here is also a gender disparity in the expert panel (16% women vs 37% men), but this is aligned with what it is observed in this profession in North America. 22his validation may support a common vision and language regarding the education of podiatrists in Canada, notwithstanding the differences in legislation and professional titles Journal of Medical Education and Curricular Development across Canada. 21This may encourage change and professional development to promote excellence and quality especially when no program accreditation is available. 23,24The experts agreed that this framework may support continuing education programs.This is seen in other professions. 25,26The CanMEDS  Mean on a maximum of 7. All items that did not meet the minimum threshold of 80% (5.6/7) went through to the second round.±Agreement on the new indicator added after the first round.

Andoulsi et al
Limitations to this study must be emphasized, as the type of sampling and the population does not necessarily represent all Canadian podiatrists, notably due to the wide variety of degrees and the fact that the experts were chosen by a specific network (CPMA).Our questionnaire was not validated.The first questionnaire was long (Supplementary Appendix A), which may have led to fatigue and less accurate responses.However, the results add value to our previous work, and the validated version represents a broader perspective to enhance the quality of our program and hopefully, the quality of podiatric care.This study may also serve as preliminary work for another similar study, but on an international scale.

Conclusion
This validation process led to the enhancement of a framework that now takes into account the expertise of many professionals across Canada focused on foot care.This framework promotes the excellence and quality of our podiatry training program and, ultimately, foot care and prevention.By implementing it locally in Canada and, hopefully, internationally, it could foster a common vision and language for consistent training among podiatrists.

Figure 1 .
Figure 1.Summary of the adapted e-Delphi process.A: Two-week deadline for completion of the round; B: Team consensus related to relevancy, comprehensiveness, and clarity.Iteration of items; X: As consensus was reached at the end of Round 2, Round 3 was not necessary.

2
framework can support potential learning needs associated with specific competencies and/or indicators.Perceived learning needs and challenges encountered in practice can provide insight into the selection and design of continuing education activities and empower the learner.25
¶This number is calculated from 37 participants included in the first round.

Table 2 .
Continued.†Theoriginal framework with description of roles, competencies and indicators is available in Blanchette et al 2022.6    ‡