Physiotherapist-supervised exercises versus unsupervised home-based exercises after nonsurgically treated proximal humerus fracture: a multicenter randomized controlled trial.

BACKGROUND: Proximal humerus fracture (PHF) is a common fragility fracture in older adults and can have a substantial impact on upper limb function. Although most patients with PHF can be treated nonsurgically, it is unknown whether older adults benefit from supervised exercise therapy after PHF. Therefore, the objective of this trial was to investigate whether 10 weeks of physiotherapist-supervised exercises once a week were superior to 10 weeks of unsupervised home-based exercises in older adults with a nonsurgically treated displaced 2-part PHF. METHODS: This was designed as an assessor-blinded, prospective, randomized controlled trial and took place in 3 Nordic countries. In total, 72 patients (≥60 years) with nonsurgically treated displaced 2-part PHF were randomized to either physiotherapist-supervised exercises once a week for 10 weeks, combined with daily home-based exercises, or to 10 weeks of daily unsupervised home-based exercises. The primary outcome measure was the Disability of the Arm, Shoulder, and Hand (DASH) with a primary endpoint at 3 months. Secondary outcomes were DASH (at 12 months), Constant-Murley Score, the 15D-instrument, Visual Analog Scale, General Self-Efficacy Scale, and Pain Catastrophizing Scale, with follow-up visits after 3 and 12 months. Non-union and patient death within 3 months were counted as complications. RESULTS: The mean age of the patients in both groups was 72 years. At 3 months follow-up, the mean DASH score in the supervised group was 25.9 (SD 16.0) compared to 22.4 (SD 18.9) in the unsupervised group. The mean between-group difference (3.5, 95% CI -5.0 to 12.5) was not clinically relevant. None of the secondary outcome measures presented any clinically relevant or statistically significant between-group differences at 3 or 12 months follow-up. One patient in the supervised group and 3 in the unsupervised group were diagnosed with non-union. One patient from each group died before 3 months follow-up. CONCLUSIONS: This trial provides no evidence that supervised exercises are superior to unsupervised home-based exercises in improving functional outcome or health-related quality of life in older patients with a nonsurgically treated 2-part PHF. Further, our results suggest that most older adults with a nonsurgically treated 2-part PHF can perform home-based exercises without the supervision of a physiotherapist.

Surgery with locking plate or hemiarthroplasty versus nonoperative treatment of 3-4-part proximal humerus fractures in older patients (NITEP): An open-label randomized trial.

BACKGROUND: Proximal humerus fractures (PHFs) are common fractures, especially in older female patients. These fractures are commonly treated surgically, but the consensus on the best treatment is still lacking. METHODS AND FINDINGS: The primary aim of this multicenter, randomized 3-arm superiority, open-label trial was to assess the results of nonoperative treatment and operative treatment either with locking plate (LP) or hemiarthroplasty (HA) of 3- and 4-part PHF with the primary outcome of Disabilities of the Arm, Shoulder, and Hand (DASH) at 2-year follow-up. Between February 2011 and December 2019, 160 patients 60 years and older with 3- and 4-part PHFs were randomly assigned in 1:1:1 fashion in block size of 10 to undergo nonoperative treatment (control) or operative intervention with LP or HA. In total, 54 patients were assigned to the nonoperative group, 52 to the LP group, and 54 to the HA group. Five patients assigned to the LP group were reassigned to the HA group perioperatively due to high comminution, and all of these patients had 4-part fractures. In the intention-to-treat analysis, there were 42 patients in the nonoperative group, 44 in the LP group, and 37 in the HA group. The outcome assessors were blinded to the study group. The mean DASH score at 2-year follow-up was 30.4 (standard error (SE) 3.25), 31.4 (SE 3.11), and 26.6 (SE 3.23) points for the nonoperative, LP, and HA groups, respectively. At 2 years, the between-group differences were 1.07 points (95% CI [-9.5,11.7]; p = 0.97) between nonoperative and LP, 3.78 points (95% CI [-7.0,14.6]; p = 0.69) between nonoperative and HA, and 4.84 points (95% CI [-5.7,15.4]; p = 0.53) between LP and HA. No significant differences in primary or secondary outcomes were seen in stratified age groups (60 to 70 years and 71 years and over). At 2 years, we found 30 complications (3/52, 5.8% in nonoperative; 22/49, 45% in LP; and 5/49, 10% in HA group, p = 0.0004) and 16 severe pain-related adverse events. There was a revision rate of 22% in the LP group. The limitation of the trial was that the recruitment period was longer than expected due to a high number of exclusions after the assessment of eligibility and a larger exclusion rate than anticipated toward the end of the trial. Therefore, the trial was ended prematurely. CONCLUSIONS: In this study, no benefit was observed between operative treatment with LP or HA and nonoperative treatment in displaced 3- and 4-part PHFs in patients aged 60 years and older. Further, we observed a high rate of complications related to operative treatments. TRIAL REGISTRATION: ClinicalTrials.gov NCT01246167.

Are progressive shoulder exercises feasible in patients with glenohumeral osteoarthritis or rotator cuff tear arthropathy?

BACKGROUND: Little is known about the feasibility of progressive shoulder exercises (PSE) for patients with glenohumeral osteoarthritis (OA) or rotator cuff tear arthropathy (CTA). The aim of this study was to investigate whether 12 weeks of PSE is feasible in patients with glenohumeral OA or CTA eligible for shoulder arthroplasty. Moreover, to report changes in shoulder function and range of motion (ROM) following the exercise program. METHODS: Twenty patients were included. Eighteen patients (11 women, 15 with OA), mean age 70 years (range 57-80), performed 12 weeks of PSE with one weekly physiotherapist-supervised and two weekly home-based sessions. Feasibility was measured by dropout rate, adverse events, pain, and adherence to PSE. At baseline and end of intervention, patients completed the Western Ontario Osteoarthritis of the Shoulder (WOOS) score and Disabilities of the Arm, Shoulder and Hand (DASH). Data to assess feasibility were analyzed using descriptive statistics. RESULTS: Two patients dropped out and no adverse events were observed. Sixteen of the eighteen patients (89%) had a high adherence (≥ 70%) to the physiotherapist-supervised sessions. Acceptable pain levels were reported; in 76% of all exercise sessions with no numeric rating scale (NRS) score over five for any exercise. WOOS improved with a mean of 23 points (95% CI 13;33), and DASH improved with a mean of 13 points (95% CI 6;19). CONCLUSION: Adherence to PSE was high and dropout rates were low. PSE is feasible, safe and may relieve shoulder pain, improve function and ROM in patients with glenohumeral OA or CTA. The patient-experienced gains after PSE seem clinically relevant and should be compared to arthroplasty surgery in a RCT setting. TRIAL REGISTRATION: According to Danish law, this study did not need an approval by the Central Denmark Region Committee on Health Research Ethics. Approval from The Danish Data Protection Agency (journal number 1-16-02-15-20) was obtained.

The impact of full-thickness rotator cuff tear on shoulder function and quality of life in patients who sustain a proximal humerus fracture-a prospective cohort study.

BACKGROUND: Only few studies have investigated the impact of rotator cuff integrity on patients with proximal humerus fracture (PHF). We aimed to determine if the presence of a rotator cuff tear impairs shoulder function and health-related quality of life (HRQoL) after nonsurgically treated PHF. METHODS: Sixty-seven patients with PHF were recruited prospectively in a cohort. Presence of a full-thickness rotator cuff tear was determined by ultrasound examination. After 6 and 12 months, Constant-Murley Score; Disability of the Arm, Shoulder and Hand; the Visual Analog Scale; EuroQol-5 Domain; and the 15D scores were compared between the patients with a rotator cuff tear and patients with an intact rotator cuff. RESULTS: The prevalence of a full-thickness rotator cuff tear was 34%. After 12 months, the mean Constant-Murley Score was 65.7 (standard deviation 16.3) in the intact rotator cuff group vs. 53.9 (16.0) in the rotator cuff tear group (mean diff. 11.8, 95% confidence interval 2.5; 21.2) and was found to be a clinically relevant difference. A significantly lower HRQoL was found on the EuroQol-5 Domain score after 12 months in the rotator cuff tear group with a median score of 1 (interquartile range 0.23) in the intact rotator cuff group vs. 0.75 (interquartile range 0.34) in the rotator cuff tear group (P = .03). In the remaining outcome measures, no statistically significant between-group differences were detected. CONCLUSION: Rotator cuff tear in older adults with nonsurgically treated PHF may be considered a prognostic factor for poorer shoulder function and HRQoL. This knowledge can support the planning of treatment.

Study protocol: Prosthesis versus Active (ProAct) exercise program in patients with glenohumeral osteoarthritis - a multicenter, randomized controlled trial.

BACKGROUND AND PURPOSE: Total shoulder arthroplasty (TSA) and shoulder exercises are both effective treatments for reducing pain and improving function in glenohumeral osteoarthritis. However, the effectiveness of TSA has not been compared with non-surgical treatment in a randomized controlled trial. We will examine whether TSA followed bystandard postsurgical rehabilitation is superior to a 12-week exercise program in patients with primary glenohumeral OA who are eligible for unilateral TSA. PATIENTS AND METHODS: In this Nordic multicenter randomized controlled clinical trial, patients with glenohumeral osteoarthritis eligible for TSA will be allocated to either TSA followed by usual care or exercise only. The exercise intervention comprises 12 weeks of exercise with one weekly physiotherapist-supervised session. Based on the sample size calculation, the trial needs to include 102 patients. Duration and outcome:  Recruitment was initiated in April 2021 and is expected to be completed by the end of March 2024. Primary outcome is patient-reported quality of life, measured as total WOOS score 12 months after initiation of treatment. The key secondary outcomes include patient-reported pain intensity at rest and during activity; Disabilities of the Arm, Shoulder, and Hand score (DASH); the use of analgesics during the previous week; and adverse events. TRIAL REGISTRATION: The trial is approved by the Central Denmark Region Committee on Biomedical Research Ethics (Journal No 1-10-72-29-21) and by the Danish Data Protection Agency (Journal No 1-16-02-199-21). ClinicalTrials.gov Identifier: NCT04845074.

The Benefits and Harms of Early Mobilization and Supervised Exercise Therapy after Non-surgically Treated Proximal Humerus or Distal Radius fracture: A systematic Review and Meta-analysis.

PURPOSE OF REVIEW: Fractures of the proximal humerus (PHF) and distal radius (DRF) are among the most common upper extremity fractures in the elderly. Recent randomized controlled trials support non-surgical treatment. Evidence behind the best non-surgical treatment strategy has been sparse and raises questions as to when and how to initiate exercises. The purpose of this systematic review and meta-analysis was to assess the benefits and harms of early mobilization versus late mobilization and supervised versus non-supervised exercises therapy after PHF and DRF. RECENT FINDINGS: 15 published and 5 unpublished trials were included. Early mobilization after PHF resulted in better function with a mean difference (MD) of 4.55 (95% CI 0.00-9.10) on the Constant Shoulder Score. However, the MD was not found to be clinically relevant. No clear evidence showed that early mobilization after PHF had a positive effect on range of motion or pain. Neither did it lead to more complications. Furthermore, no eligible evidence was found supporting early mobilization to be superior to late mobilization after DRF, or that supervised exercise therapy was superior to non-supervised exercise therapy after PHF and DRF. The quality of evidence on all outcomes was found to be low or very low. Early mobilization after PHF may have a beneficial effect on function. Due to the lack of clear evidence, there is an urgent need for future studies to determine the effect of early mobilization and supervised exercise therapy after PHF and DRF. Prospero ID number: CRD42020167656, date of registration 28.04.2020.

An iliopsoas plane block does not cause motor blockade-A blinded randomized volunteer trial.

BACKGROUND: A femoral nerve block relieves pain after total hip arthroplasty, but its use is controversial due to motor paralysis accompanied by an increased risk of fall. Assumedly, the iliopsoas plane block (IPB) targets the hip articular branches of the femoral nerve without motor blockade. However, this has only been indicated in a cadaver study. Therefore, we designed this volunteer study. METHODS: Twenty healthy volunteers were randomly allocated to blinded paired active vs. sham IPB (5 mL lidocaine 18 mg/mL with epinephrine vs saline). The primary outcome was reduction of maximal force of knee extension after IPB compared to baseline. Secondary outcomes included reduction of maximal force of hip adduction, and the pattern of injectate spread assessed with magnetic resonance imaging. RESULTS: Mean (confidence interval) change of maximal force of knee extension from baseline to after IPB was -9.7 N (-22, 3.0) (P = .12) (n = 14). The injectate was consistently observed in an anatomically well-defined closed fascial compartment between the intra- and extra-pelvic components of the iliopsoas muscle anterior to the hip joint. CONCLUSION: We observed no significant reduction of maximal force of knee extension after an IPB. The injectate was contained in a fascial compartment previously shown to contain all sensory branches from the femoral nerve to the hip joint. The clinical consequence of selective anesthesia of all sensory femoral nerve branches from the hip could be a reduced risk of fall compared to a traditional femoral nerve block. Registration of Trial: The trial was prospectively registered in EudraCT (Reference: 2018-000089-12, https://www.clinicaltrialsregister.eu/ctr-search/search?query=2018-000089-12).

Operative versus non-operative treatment for 2-part proximal humerus fracture: A multicenter randomized controlled trial.

BACKGROUND: Although increasingly used, the benefit of surgical treatment of displaced 2-part proximal humerus fractures has not been proven. This trial evaluates the clinical effectiveness of surgery with locking plate compared with non-operative treatment for these fractures. METHODS AND FINDINGS: The NITEP group conducted a superiority, assessor-blinded, multicenter randomized trial in 6 hospitals in Finland, Estonia, Sweden, and Denmark. Eighty-eight patients aged 60 years or older with displaced (more than 1 cm or 45 degrees) 2-part surgical or anatomical neck proximal humerus fracture were randomly assigned in a 1:1 ratio to undergo either operative treatment with a locking plate or non-operative treatment. The mean age of patients was 72 years in the non-operative group and 73 years in the operative group, with a female sex distribution of 95% and 87%, respectively. Patients were recruited between February 2011 and April 2016. The primary outcome measure was Disabilities of Arm, Shoulder, and Hand (DASH) score at 2-year follow-up. Secondary outcomes included Constant-Murley score, the visual analogue scale for pain, the quality of life questionnaire 15D, EuroQol Group's 5-dimension self-reported questionnaire EQ-5D, the Oxford Shoulder Score, and complications. The mean DASH score (0 best, 100 worst) at 2 years was 18.5 points for the operative treatment group and 17.4 points for the non-operative group (mean difference 1.1 [95% CI -7.8 to 9.4], p = 0.81). At 2 years, there were no statistically or clinically significant between-group differences in any of the outcome measures. All 3 complications resulting in secondary surgery occurred in the operative group. The lack of blinding in patient-reported outcome assessment is a limitation of the study. Our assessor physiotherapists were, however, blinded. CONCLUSIONS: This trial found no significant difference in clinical outcomes at 2 years between surgery and non-operative treatment in patients 60 years of age or older with displaced 2-part fractures of the proximal humerus. These results suggest that the current practice of performing surgery on the majority of displaced proximal 2-part fractures of the humerus in older adults may not be beneficial. TRIAL REGISTRATION: ClinicalTrials.gov NCT01246167.

Consensus on technical procedures for simulation-based training in anaesthesiology: A Delphi-based general needs assessment.

BACKGROUND: Anaesthesiologists are expected to master an increasing number of technical procedures. Simulation-based procedural training can supplement and, in some areas, replace the classical apprenticeship approach during patient care. However, simulation-based training is very resource-intensive and must be prioritised and optimised. Developing a curriculum for simulation-based procedural training should follow a systematic approach, eg the Six-Step Approach developed by Kern. The aim of this study was to conduct a national general needs assessment to identify and prioritise technical procedures for simulation-based training in anaesthesiology. METHODS: A three-round Delphi process was completed with anaesthesiology key opinion leaders. In the first round, the participants suggested technical procedures relevant to simulation-based training. In the second round, a needs assessment formula was used to explore the procedures and produce a preliminary prioritised list. In the third round, participants evaluated the preliminary list by eliminating and re-prioritising the procedures. RESULTS: All teaching departments in Denmark were represented with high response rates in all three rounds: 79%, 77%, and 75%, respectively. The Delphi process produced a prioritised list of 30 procedure groups suitable for simulation-based training from the initial 138 suggestions. Top-5 on the final list was cardiopulmonary resuscitation, direct- and video laryngoscopy, defibrillation, emergency cricothyrotomy, and fibreoptic intubation. The needs assessment formula predicted the final prioritisation to a great extent. CONCLUSION: The Delphi process produced a prioritised list of 30 procedure groups that could serve as a guide in future curriculum development for the simulation-based training of technical procedures in anaesthesiology.

The Use of Ultrasound to Exclude Extremity Fractures in Adults.

BACKGROUND: The purpose of the present study was to investigate whether ultrasonography can be used as a diagnostic tool to exclude extremity fractures in adults. METHODS: This prospective comparative study involved 91 patients (age, ≥18 years) who had been referred by general practitioners for a conventional radiographic examination of a suspected extremity fracture. No additional clinical examination was performed. Ultrasound examination was consistently carried out prior to conventional radiographic examination, which was regarded as the gold standard. At the end of the study, the positive scans were confirmed by a specialist who was highly skilled in ultrasonography. RESULTS: The prevalence of fractures in the study population was 27%. Ultrasonography had a sensitivity of 92%, a specificity of 94%, a positive predictive value of 85%, a negative predictive value of 97%, a positive likelihood ratio of 15.33, and a negative likelihood ratio of 0.085. There seemed to be no association between the anomalous results and patient age or the specific anatomical region of the fracture. CONCLUSIONS: The present study indicates that ultrasonography, when performed and interpreted by experienced ultrasonographers, has high accuracy for the diagnosis of a suspected extremity fracture. No systematic differences were found between the results of radiography and ultrasonography, and ultrasonography showed a high sensitivity and specificity. LEVEL OF EVIDENCE: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Prevalence and predictors of musculoskeletal pain among Danish fishermen - results from a cross-sectional survey.

BACKGROUND: Fishermen work in a physically challenging work environment. The aim of this analysis was to estimate the prevalence and predictors of musculoskeletal pain among Danish fishermen. METHOD: A cross-sectional survey in a random sample of Danish fishermen was done with application of the Nordic questionnaire regarding musculoskeletal pain considering lower back, shoulders, hand neck, knee, upper back elbow, hip and feet. In total, 270 fishermen participated in the study (response rate: 28%). Workload, vessel type, skipper, duration of work, sideline occupation, days/weeks of fishing at sea, age, BMI and education were used as predictors for the overall musculoskeletal pain score (multiple linear regression) and for each single pain site (multinomial logistic regression). RESULTS: The prevalence of pain was high for all musculoskeletal locations. Overall, more than 80% of the responding Danish fishermen reported low back pain, which in 37% lasted for a minimum of 30 days during the past year. In the multiple linear regression analysis, middle workload was associated with a 32% (95% CI: 19-46%) and high workload with 60% (95% CI: 46-73%) increased musculoskeletal pain score compared to low work load. Multinomial logistic regression models showed that workload was the only predictor for all pain sites, in particular regarding upper and lower limb pain. CONCLUSION: Although changes were implemented to improve the fishermen's work environment, the work continues to be physically demanding and impacting their musculoskeletal pain. Potential explanation for this unexpected result like increased work pressure and reduced financial attractiveness in small scale commercial fishery needs to be confirmed in future research.

The workload of fishermen: a cross sectional survey among Danish commercial fishermen.

BACKGROUND: Fishery has always been perceived as a physically demanding industry of a manual character. In recent years the physical work environment has developed positively and consequently the current situation in not fully described in the existing literature. This study aims to describe the work environment of Danish fishermen with regard to their physical workload and ergonomic factors. MATERIALS AND METHODS: A cross sectional study was performed on a random sample of active Danish commercial fishermen (response rate: 28%) by means of a questionnaire on demographic and self-reported occupational and health data. Questions covering the physical workload were related to seven different work situations and a score summing up the workload was developed for the analysis of the relative impact on different groups of fishermen. RESULTS: Almost all fishermen (96.2%) were familiar to proper lifting techniques but only 55.4% used them in their daily work. Standing work was the most applied work position (81.8%), while repetitive hand and finger movements and twisting and bending in the back were other frequent work situations. Deckhands had higher workload scores than skippers, while crew on Danish seiners had higher workload scores than fishermen in other vessel types. CONCLUSIONS: Despite improved work environment in the Danish fishing industry, fishermen still experience high levels of workload and suboptimal ergonomic conditions, which are known to cause pain and impair musculoskeletal health. To address the specific areas of fishing with the highest workload, future investments in assistive devices to ease the demanding work and reduce the workload, should particularly address deckhands and less mechanized vessels.

[The Danish introductory position provides a qualified choice of specialty]. / Introduktionsstillingen giver et godt grundlag for kvalificeret specialevalg.

The Danish introductory position is unique. It is placed between internship and the main part of specialist education. Workplace-based assessment according to central objectives is central. The purpose of the introductory position is twofold: the resident is introduced to the specialty - the specialty choice is thus based on a context-based personal experience, and the specialties can assess the potential and suitability of the resident. Also opportunities for career counselling are strengthened. In this way both choice of specialty and selection into the specialties is qualified.

[High standards of educational climate in Danish anaesthesiological departments]. / Godt uddannelsesmiljø inden for anæstesiologien.

For the first time since the implementation of the Danish national medical educational reform in 2004 the effects on the educational programme are investigated by means of a nation-wide questionnaire. Mandatory concepts introduced with the educational reform such as supervisor involvement, appraisal meetings and personal learning plans are almost completely implemented in the anaesthesiological departments. Doctors, who do not currently undertake specialist training, were also contented with the implementation. The educational climate is reported to be of high standards. Hopefully, this survey can inspire other specialities to identify how education can be improved.

[Rater bias in postgraduate medical education]. / Bedømmerbias i speciallægeuddannelsen.

In-training assessment is a cornerstone in outcome based postgraduate medical education. When assessing the trainee the trainer should be aware of potential pitfalls and biases and how to avoid these. This paper summarises assessor biases and pitfalls and gives recommendations on how to avoid these.

[Implementation of a national training assessment programme in anaesthesiology]. / Implementering af nationalt kompetenceprogram i anaestesiologi.

INTRODUCTION: In 2004, outcome-based education and in-training assessment was introduced by a reform of postgraduate medical education in Denmark. An assessment programme covering the introductory year of anaesthesiology was constructed. The purpose of this study was to explore to which degree this programme was implemented in daily practice in the clinical departments and whether the recommended assessment protocol was followed. MATERIALS AND METHODS: A questionnaire was distributed to 26 departments and 38 trainees. RESULTS: The response rate for both groups exceeded 90%. Individual learning plans were prepared by (2/3) of the trainees according to both trainees and departments. The various methods in the assessment programme were implemented to a high degree. The use of structured clinical observations was reported by more than 70% of both groups. Global assessments were applied in more than 70% according to both groups. Fifty percent of the trainees and 70% of the departments reported that these were used in accordance with recommendations. The trainees profited from preparing the written assignments, but only half of them found that they were used in accordance with recommendations. In contrast, more than 90% of the departments reported that the assignments were implemented according to recommendations. Practical completion of in-training assessment was considered difficult by 67% of the departments and 30% of trainees. The workload was the primary difficulty reported. CONCLUSION: In conclusion, the in-training assessment programme of the introductory year of anaesthesia has been implemented to a high degree and the assessment protocol is used according to recommendations.

[Are Danish medical students concerned about their future job? A questionnaire study]. / Er danske medicinstuderende bekymrede i relation til deres fremtidige virke? En spørgeskemaundersøgelse.

INTRODUCTION: Knowledge about the thoughts of Danish medical students regarding their job future is limited. The aim of this study was to investigate whether medical students are concerned about their future work, and if so, to describe the types of concerns they have, to what degree they are concerned, possible reasons for and consequences of their concerns; furthermore, to evaluate if gender and semester influate on the concerns. METHOD: A questionnaire was developed based on focus group interviews with medical students. The questionnaire was sent to 596 medical students from 3rd, 8th, and 13th semester at Copenhagen University. RESULTS: The response rate was 69.9%. A substantial number of students (47-90%) were very concerned or concerned to a certain degree with regard to aspects of working life that related to the patient and working conditions. A positive relation was seen between being highly concerned or concerned to a certain degree and daily or often worrying. Possible causes of the concerns were related to their experience through their clinical stays, the curriculum, comments about the job made by medical doctors and others and their own personality. Every sixth student had considered leaving university or refraining from entering clinical training due to these concerns. CONCLUSION: Medical students from 3rd, 8th, and 13th semester are concerned about their future work, especially in relation to the patient, regarding, for example, the risk of committing an error or being incompetent in relation to practical skills, but also work-related concerns are mentioned.

[Skills in management, co-operation and communication in the Pre-Registration House Officership]. / Faerdigheder i ledelse, samarbejde og kommunikation i turnusuddannelsen.

INTRODUCTION: In aviation, it has been realised that technical training ensures competence in specific procedures, but does not counter errors due to communication or decision making in a dynamic environment. As a consequence, Crew Resource Management, consisting of training in co-operation, management, and communication skills, was introduced in order to serve as a countermeasure towards human errors. In the same way, medical school ensures academic and technical insight, but rarely offers systematic training in such non-technical skills. The aim of this study is to identify the standard of competence in skills of co-operation, management, and communication at the end of the Pre-Registration House Officership. METHOD: 30 skills of management, co-operation, and communication divided into five main areas were identified. Using the Delphi method through two rounds of questionnaires, an expert panel of 50 doctors evaluated six different standards of competence for each skill. RESULTS: The Panel reached consensus at a 75% level for five skills, all within the main area "Team communication in the acute situation". Consensus was not reached within any of the other four main areas. None of the 30 skills was evaluated as being irrelevant for the Pre-Registration House Officer by more than one panel member. CONCLUSION: There was broad agreement on the need for high standards of competence within the area of team communication. There was considerable disagreement within the panel with regard to the other main areas, but all of the skills listed in this study were found relevant to the Pre-Registration House Officer in the acute situation.