In order to determine the best training method, this study consisted at first in an analysis of the current courses including training on or exclusively about corticosteroid injections, ongoing in the field of continuing medical education. This evaluation was designed to be conducted through the dissemination of a survey to each general practitioner that either attended to a training session in 2017 or followed an online training course at any time during this same year in France. As it was clearly identified that the design of this survey (lying on voluntary answers) could be responsible of a risk of low response rates, as experienced in previous studies and doctoral theses, thus representing a potential significant selection bias, it was therefore decided that this first part of the study would be analysed in the light of a second part consisting in a literature review. This one was concerned with the efficiency of current training courses and teaching policies in other countries as well as with studies on new technical skills acquisition, such as those related to basic acts in the surgical practice. The main evaluation criterion was the efficiency of different training course models in terms of technical abilities of the trainees and benefits for patients as well as for the health care system.
Physicians’ survey
In order to ensure the comparability of the different training courses, we took the decision to restrict the analyses to those certified by the French national agency of continuing medical education, because of their asserted quality due to the imposed requirements and specifications. Through a screening on the corresponding website (www.agencedpc.fr) of the former and currently available training courses regarding exclusively or partially corticosteroid injections in either the knee or the shoulder or both articulations, we thus identified 10 programs carried out by 8 training institutes. There were 9 on-site training courses, divided in 19 sessions, and 1 online training course by e-learning. The main characteristics of each training course are summarized in Table I.
A survey (see translated version in Additional file 1), assessing demographic data and questions on perceived changes in skills by general practitioners that had taken part in one of these training courses and on the impact in modifying their practice, was addressed by electronic mail to each institute. Repeated phone reminders were also performed with the aim of obtaining a higher rate of answers. Statistical analyses were performed using Microsoft® Excel and the BiostaTGV online software. It consisted in a Student t-test or a linear regression as required depending on the type of data, the degree of statistical significance (α) was defined as 0.05.
The survey was addressed to physicians, it did not concern data about patients and it did not interfere with the patients' care, its purpose did not consist in the development of biological knowledge or medical guidelines. Indeed, in compliance with the decree 2017 − 884 of 9th May 2017, a need for consent was deemed unnecessary according to French regulations. This protocol has been approved by the ethics committee of Le Mans General Hospital.
Literature review
Concerning the literature review, a global search was done inside the Medline database using keywords arranged in the following request: (((("arthrocentesis"[MeSH Terms]) OR "biopsy, fine needle"[MeSH Terms]) OR "injections, intra articular"[MeSH Terms])) AND (((((((("education, medical"[MeSH Terms]) OR "education, medical, continuing"[MeSH Terms]) OR "learning curve"[MeSH Terms]) OR ("task performance and analysis"[MeSH Terms])) OR "teaching"[MeSH Terms]) OR "learning"[MeSH Terms]) OR "general practice"[MeSH Terms]) OR "rheumatology/education"[MeSH Terms]). Only articles written in French or English with an available abstract were retained in the initial selection. There was no other restriction, particularly no limitation in the date of publication as well as in the age of the involved subjects, veterinary studies were also considered. In order to complete this screening, it was there implemented by additional published studies, linked with the previous ones when identified as similar, if they were judged potentially relevant for the topic on the basis of their title. After removal of duplicates, a pool of 160 articles was left. Then 108 studies were excluded after reading the abstract because they did not evaluate training methods for teaching injections. Similarly, 33 other studies were excluded after reading the full text of the article for the same reason and 1 more as it was the preliminary study of another one included in the literature review. There were thus 18 remaining articles. The whole selection process is described in Fig. 1.
The methodological quality of the included studies was appraised using either CONSORT, SQUIRE or STROBE checklists, as required according to the design of the study, and according to the publishing journal’s last available Impact Factor. These considerations are represented in Fig. 2.
An exclusion of the studies with a poor methodological quality, arbitrarily predefined as a score lower than 60 percent in the appropriate score (meaning a score lower than 15 points out of 25 using the CONSORT checklist, 12 points out of 19 using the SQUIRE checklist or 14 out of 22 using the STROBE checklist), was intended but none met this criterion.