Factors affecting nurses' decision to undergo a specialist education and to choose a specialty.

AIMS: The aims of the study were to identify factors affecting nurses' decision to undergo specialist education and choose a specialty and to describe differences between specialization areas with different types of care. DESIGN: A descriptive cross-sectional design. METHODS: A survey was conducted among specialist nurse students in three nursing colleges in Sweden (n = 227). Instruments such as Big Five Inventory and RAND-36 and items earlier used by Bexelius and Olsson were included. Survey data were analysed by using descriptive and analytical statistics, and for open-ended question qualitative content analysis was used. RESULTS: Wage benefit during the education was regarded by 47% as an incentive to start studies. Most of the specialist nurse students considered an opportunity for new tasks (75%), new areas of responsibility (75%), intellectual challenges (72%) and higher wages (71%) to be of high importance when choosing a specialty. However, the students in specialization areas with transitory care-rated challenges regarding the practical skills (84%) and the occurrence of acute events (82%) higher. CONCLUSION: Although higher wages were important to make nurses feel that they will get value from the education, there were also other important aspects, such as opportunity for new tasks, new areas of responsibility and intellectual challenges that influenced nurses' willingness to undergo a specialist education. Our findings provide employers with the useful information to guide and influence nurses' decisions to enter specialist education and their choice of specialist area.

Evaluation of interprofessional teamwork modules implementation in an emergency department - A mixed-methods case study of implementation fidelity.

BACKGROUND: The need for interprofessional collaboration has been emphasized by health organizations. This study was part of a mixed-methods evaluation of interprofessional teamwork modules implementation in an emergency department (ED), where a major intervention was didactic training of team roles and behaviours in combination with practice scenarios. The aim of the study was to evaluate the implementation of interprofessional teamwork modules from a staff perspective and focus on how implementation fidelity may be sustained. METHODS: In this mixed-methods case study we triangulated staff data from structured observations, semi-structured interviews, and a questionnaire repeated at intervals over 5 years. A protocol of key team behaviours was used for the observations conducted in June 2016 and June 2018, 1½ and 3½ years after the initial implementation. A purposeful sample of central informants, including nursing and medical professionals and section managers, was interviewed from May to June 2018. The interview guide consisted of open-ended questions about the experiences of interprofessional teamwork modules and the implementation process. The questionnaire consisted of five statements about the perceived workload, interprofessional collaboration and patient satisfaction, where each was rated on a Likert scale. RESULTS: Good fidelity to four out of five key team behaviours was observed during the first year. However, fidelity was sustained only for one key team behaviour after 3 years. We conducted a qualitative content analysis of 18 individual interviews. The theme Enjoying working together, but feeling less efficient emerged of the interprofessional teamwork modules, despite shorter ED stays for the patients. Negative experiences of the staff included passive team leaders and slow care teams. The theme Stimulating to create, but challenging to sustain emerged of the implementation process, where barriers were not adressed and implementation fidelity not sustained. The staff questionnaire showed that the perceived work conditions was improved in periods of high fidelity, but deteriorated to pre-implementation levels as fidelity to the key team behaviours decayed in 2018. CONCLUSIONS: Extensive planning and successful initial implementation were not enough to sustain the key behaviour changes in the study. The use of implementation frameworks can be helpful in future projects.

Risk of SARS-CoV-2 exposure among hospital healthcare workers in relation to patient contact and type of care.

AIM: We aimed to assess prevalence of IgG antibodies to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and factors associated with seropositivity in a large cohort of healthcare workers (HCWs). METHODS: From 11 May until 11 June 2020, 3981 HCWs at a large Swedish emergency care hospital provided serum samples and questionnaire data. Presence of IgG antibodies to SARS-CoV-2 was measured as an indicator of SARS-CoV-2 exposure. RESULTS: The total seroprevalence was 18% and increased during the study period. Among the seropositive HCWs, 11% had been entirely asymptomatic. Participants who worked with COVID-19 patients had higher odds for seropositivity: adjusted odds ratio 1.96 (95% confidence intervals 1.59-2.42). HCWs from three of the departments managing COVID-19 patients had significantly higher seroprevalences, whereas the prevalence among HCWs from the intensive care unit (also managing COVID-19 patients) was significantly lower. CONCLUSIONS: HCWs in contact with SARS-CoV-2 infected patients had a variable, but on average higher, likelihood for SARS-CoV-2 infections.

Successful implementation of change in postgraduate medical education - a qualitative study of programme directors.

INTRODUCTION: Leaders in postgraduate medical education are responsible for implementing educational change. Although difficulties in implementing change are described both in the general leadership literature as well as in the field of medical education, knowledge of what characterises successful change leadership in postgraduate medical education is limited. The aim of this study is to explore the process used by educational leaders in successful change implementation in postgraduate medical education. METHODS: Semi-structured interviews were conducted with 16 programme directors to explore how they had implemented successful change projects. The sample consisted of programme directors who had reported in a previous survey having high educational impact at their workplace. Interviews were analysed using Ödman's qualitative interpretative method. RESULTS: The interviews identified similarities in how participating programme directors had implemented changes. Five interconnected themes crystallised from the data: (1) belonging to a group, (2) having a vision and meaning, (3) having a mandate for change, (4) involving colleagues and superiors, and (5) having a long-term perspective. CONCLUSIONS: Our findings illuminate important aspects of successful change management in postgraduate medical education. Change is ideally based on a clear vision and is implemented in coalition with others. A long-term strategy should be planned, including involvement and anchoring of key persons in several discrete steps as change is implemented. While some of these findings are congruent with the general literature on change management, this study emphasises the importance of a mandate, with successful change leadership dependent on coalition and the facilitation provided by the next level of leadership.

Can dedicated emergency team and area for older people reduce the hospital admission rate? - An observational pre- and post-intervention study.

BACKGROUND: Emergency department (ED) care of older patients is often complex. Geriatric ED guidelines can help to meet this challenge. However, training requirements, the use of time-consuming tools for comprehensive geriatric assessment (CGA), a lack of golden standard to identify the frail patients, and the weak evidence of positive outcomes of using CGA in EDs pose barriers to introduce the guidelines. Dedicating an interprofessional team of regular ED medical and nursing staff and an older-friendly ED area can be another approach. Previous studies of geriatrician-led CGA in EDs have reported a reduced hospital admission rate. The aim of this study was to investigate whether a dedicated interprofessional emergency team also can reduce the hospital admission rate without the resources required by the formal use of CGA. METHODS: An observational pre-post study at a large adult ED, where all patients 80 years or older arriving on weekdays in the intervention period from 2016.09.26 to 2016.11.28 and the corresponding weekdays in the previous year from 2015.09.28 to 2015.11.30 were included. In the intervention period, older patients either received care in the geriatric module by the dedicated team or in the regular team modules for patients of mixed ages. In 2015, all patients received care in regular team modules. The primary outcome measure was the total hospital admission rate and the ED length of stay was the secondary outcome measure. RESULTS: We included 2377 arrivals in the intervention period, when 26.7% (N = 634) received care in the geriatric module, and 2207 arrivals in the 2015 period. The total hospital admission rate was 61.7% (N = 1466/2377) in the intervention period compared to 64.8% (N = 1431/2207) in 2015 (p = 0.03). The difference was larger for patients treated in the geriatric module, 51.1% compared to 62.1% (95% CI: 56.3 to 68.0%) for patients who would have been eligible in 2015. The ED length of stay was longer in the intervention period. CONCLUSIONS: An interprofessional team and area dedicated to older patients was associated to a lower hospital admission rate. Further studies are needed to confirm the results.

Personality and learning styles in relation to attitudes towards interprofessional education: a cross-sectional study on undergraduate medical students during their clinical courses.

BACKGROUND: Interprofessional Education (IPE) is now included in curricula in universities worldwide. It is known that there are differences in attitudes towards IPE among students, but less is known regarding how students' personalities and learnings styles correspond with those attitudes. The aim of this study was to investigate whether personality traits and learning styles have any impact on medical students' attitudes towards IPE. METHODS: Seventy nine medical students in their 9th term (63% females, mean age 29 years) were questioned regarding their attitudes towards IPE according to the Interdisciplinary Education Perception Scale questionnaire, the Kolb's learning style and Big Five Inventory questionnaires. For all three instruments we used the Swedish translated versions. RESULTS: When investigated with a logistic regression, adjusting for age and gender, there were no significant associations between Big Five inventory, Kolb's learning style and IEPS, except for the Reflective-Pragmatic learning style that was moderately associated with a higher IEPS score. CONCLUSION: There was no clear correlation between personality, learning style and attitude towards IPE as measured by the IEPS among medical students in our study population. Further investigations would benefit from a combination of qualitative and quantitative design.

Inter-cultural and cross-cultural communication through physicians' lens: perceptions and experiences.

OBJECTIVES: This study aimed to explore Swedish physicians' perceptions regarding physician-patient communication in an Iranian context and to obtain a deeper understanding of their lived experience when encountering Middle Eastern and Swedish patients in their daily work. METHODS: This is a multi-method study, including conventional content analysis in combination with phenomenological methodology. A triangulation approach to data collection and analysis was used. Serving the purpose of the study, twelve Swedish physicians with previous experience of Middle Eastern patients were purposely selected to participate in the study. They watched a video showing simulated patient encounter in an Iranian context. The video served as a trigger. Semi-structured interviews were conducted focusing on the participants' perceptions of the video and their lived experiences. Constant comparative analysis was used for a deep understanding of the data. RESULTS: The core themes were cultural diversity, doctor-centeredness, and patient-centeredness. Cultural diversity was a convergent theme and included trust, interpersonal interaction, context, and doctor dominancy. Patient-centeredness and doctor-centeredness were divergent themes and included doctors' authority, equity, the experience of illness, and accountability. CONCLUSIONS: The participants confirmed large cultural differences in doctor-patient communication when encountering Iranian and Swedish patients. Inter-cultural and cross-cultural competencies were made visible. To be able to appreciate other cultures' health values, beliefs, and behaviors, increased cultural competence in health care is of importance.

Intervention with an educational video after a whiplash trauma - a randomised controlled clinical trial.

Background and aims Previous systematic reviews have considered that providing patient information is ineffective for patients with whiplash-associated disorders (WAD), with the exception of interventional educational videos. The aim of this randomised controlled clinical trial was to determine if use of an educational video as an intervention in the acute stage after a whiplash injury might improve self-reported recovery at 6 months after the injury. Methods In total, 289 consecutive patients with a whiplash injury following a motor vehicle collision were randomised to an intervention group (educational video) or to a control group (written information sheet). The video focused on information about pain mechanisms, deep flexor physiotherapy and reassurance. Emailed questionnaires were used to collect baseline data within 2 weeks after the accident and then to collect outcome data at 6 months post-injury. Non-responders were followed up with a brief telephone interview regarding the outcome. The primary outcome measure was self-reported recovery (yes/no) at 6 months post-injury. The secondary outcomes measures were pain level according to a numeric rating scale (NRS) and the whiplash disability questionnaire (WDQ) score at the same time point. Results The response rate for the baseline questionnaire was 70% (203/289). The follow-up rate was 97% (196/203). The non-recovery rates were similar between the intervention group, at 37.9% (39/103), and the control group, at 33.3% (31/93) (p = 0.55). No differences between the groups were noted in pain levels, NRS scores (1.9 vs. 2.2, p = 0.35) or the mean WDQ scores (17.5 vs. 21.2, p = 0.42). Conclusions The intervention with the educational video used in this study had no effect on the non-recovery rate when compared to a basic written information sheet. Implications The results of this trial add knowledge to the area of patient education for patients with acute WAD. Further studies are needed before the current recommendations for patient information are modified.

Factors related to the role of programme directors in association with quality in postgraduate medical education - a cross-sectional study.

BACKGROUND: Educational leaders have been pointed out as being important for quality of medical education. However, their actual influence on the education can be limited. At the postgraduate level, educational leadership and its connection with quality is underexplored and knowledge about how to increase its impact is lacking. An increased understanding could be used in order to prioritize actions for strengthening the role. The aim of this study was to investigate factors related to the role of programme director associated with quality in postgraduate medical education. METHODS: A cross-sectional study was carried out. A questionnaire was sent to programme directors in Sweden (n = 519) comprising questions about background factors, work characteristics, work tasks, hindering and enabling factors, and the Utrecht Work Engagement Scale. A logistic regression and classification tree were used to identify factors associated with high qualitative education, defined as compliance with national regulations. RESULTS: The response rate was 54% (n = 279). In total, 62% of the programme directors reported high quality and factors associated with high quality included experiences of communication with residents, superiors and supervisors, and support from the supervisors. Other factors were consensus regarding postgraduate medical education at the workplace, adequate financial resources, the programme directors' competence, and their perceived impact on education. Factors of particular importance seemed to differ depending on whether the programme directors were responsible for one or for multiple units. Most high-quality education was found in cases where programme directors were responsible for a single unit and perceived sufficient impact on education. CONCLUSIONS: These results indicated that there was an association between factors related to programme director and quality in postgraduate medical education. The findings pointed out the importance of combining activities at both individual, group and organizational levels. Relational aspects should not be underestimated; faculty development and involvement are crucial.

Association between cervical degeneration and self-perceived nonrecovery after whiplash injury.

BACKGROUND CONTEXT: Pre-existing radiological degenerative changes have not previously been considered a risk factor for nonrecovery from neck pain due to motor vehicle accidents (MVA). Results from previous studies are however often based on assessment of plain radiography or MRI and little consideration has been given to facet joints. Furthermore, previous studies have often lacked a validated scoring system for degenerative changes. PURPOSE: To investigate the association between cervical degeneration on computed tomography (CT) and nonrecovery after whiplash trauma. STUDY DESIGN: Longitudinal cohort study. PATIENT SAMPLE: One hundred twenty-one patients attending the Emergency Department because of neck pain after MVA, 2015-2017, with a valid CT-scan of the cervical spine and completion of follow up after 6 months. OUTCOME MEASURES: The primary outcome measure was self-perceived nonrecovery (yes/no) after 6 months. A secondary outcome measure was self-reported pain level (Numeric Rating Scale). METHODS: Baseline data regarding demographics and health factors were gathered through a web-based questionnaire. Degeneration of facet joints and intervertebral discs was assessed on CT-scans according to a validated scoring system. Binary logistic regression was used to study the association between cervical degeneration and nonrecovery. RESULTS: Moderate facet joint degeneration was associated with nonrecovery. In the group with moderate degree of facet joint degeneration, 69.6% reported nonrecovery compared with 23.6% among patients without any signs of degeneration (adjusted odds ratio 6.7 [95% confidence interval: 1.9-24.3]). There was no association between disc degeneration and nonrecovery. Combined facet joint degeneration and disc degeneration were associated with nonrecovery (adjusted odds ratio 6.2 [2.0-19.0]). CONCLUSIONS: These results suggest that cervical degeneration, especially facet joint degeneration, is a risk factor for nonrecovery after whiplash trauma. We hypothesize that whiplash trauma can be a trigger for painful manifestation of previously asymptomatic facet joint degeneration.

Interprofessional teamwork versus fast track streaming in an emergency department-An observational cohort study of two strategies for enhancing the throughput of orthopedic patients presenting limb injuries or back pain.

OBJECTIVE: To compare two strategies, interprofessional teams versus fast track streaming, for orthopedic patients with limb injuries or back pain, the most frequent orthopedic complaints in an emergency department. METHODS: An observational before-and-after study at an adult emergency department from May 2012 to Nov 2015. Patients who arrived on weekdays from 8 am to 9 pm and presented limb injury or back pain during one year of each process were included, so that 11,573 orthopedic presentations were included in the fast track period and 10,978 in the teamwork period. Similarly, another 11,020 and 10,760 arrivals presenting the six most frequent non-orthopedic complaints were included in the respective periods, altogether 44,331 arrivals. The outcome measures were the time to physician (TTP) and length of stay (LOS). The LOS was adjusted for predictors, including imaging times, by using linear regression analysis. RESULTS: The overall median TTP was shorter in the teamwork period, 76.3 min versus 121.0 min in the fast track period (-44.7 min, 95% confidence interval (CI): -47.3 to -42.6). The crude median LOS for orthopedic presentations was also shorter in the teamwork period, 217.0 min versus 230.0 min (-13.0 min, 95% CI: -18.0 to -8.0), and the adjusted LOS was 22.8 min shorter (95% CI: -26.9 to -18.7). For non-orthopedic presentations, the crude median LOS did not differ significantly between the periods (2.0 min, 95% CI: -3.0 to 7.0). However, the adjusted LOS was shorter in the teamwork period (-20.1 min, 95% CI: -24.6 to -15.7). CONCLUSIONS: The median TTP and LOS for orthopedic presentations were shorter in the teamwork period. For non-orthopedic presentations, the TTP and adjusted LOS were also shorter in the teamwork period. Therefore, interprofessional teamwork may be an alternative approach to improve the patient flow in emergency departments.

Regional or General Anesthesia in the Surgical Treatment of Distal Radial Fractures: A Randomized Clinical Trial.

BACKGROUND: Most patients undergoing surgery for the treatment of a distal radial fracture are treated in a day-surgery setting and are given either general anesthesia (GA) or regional anesthesia (RA). The main purpose of this study was to investigate the impact of the anesthesia method on patients' postoperative opioid consumption during the first 3 days following surgery. METHODS: This was a single-center randomized clinical trial. A total of 88 patients aged 18 to 74 years who were undergoing day surgery for the treatment of a displaced distal radial fracture with volar-plate fixation were randomized to GA (n = 44) or RA with a supraclavicular brachial plexus blockade (n = 44). The primary outcome was total opioid equivalent consumption (OEC) during the first 3 postoperative days (72 hours). Secondary outcomes included OEC during days 1, 2, and 3, visual analog scale (VAS) for pain scores, maximum pain, postoperative nausea and vomiting, perioperative time consumption (surgical, preoperative, and postoperative anesthesia care time), functional outcomes, and Patient-Rated Wrist Evaluation (PRWE) and EuroQol-5 Dimensions-3 Levels (EQ-5D-3L) scores up to 6 months. RESULTS: The total median OEC during the first 3 postoperative days was 85 mg (range, 0 to 218 mg) in the GA group and 60 mg (range, 3 to 150 mg) in the RA group (p = 0.1). The groups differed significantly in OEC and VAS for pain scores during the first 24 hours after surgery; the median OEC was higher in the GA group before discharge (p < 0.001), while it was higher in the RA group after discharge (p < 0.001). Patients in the GA group reported more pain immediately after surgery (median score, 6; width of interquartile range [IQR], 7) and at 2 hours postoperatively (median score, 2; width of IQR, 3) compared with patients in the RA group (median score, 0; width of IQR, 0 at both time points) (p < 0.001). Maximum pain occurred at a median of 1 hour (range, 1 hour to 22 hours) after the end of surgery in the GA group compared with a median of 11 hours (range, 1 hour to 24 hours) in the RA group (p < 0.001). The total median perioperative time consumption was 244 minutes (range, 114 to 389 minutes) in the GA group compared with 146 minutes (range, 74 to 390 minutes) in the RA group (p < 0.001). There were no significant differences in functional outcomes or PRWE or EQ-5D-3L scores at 6 months. CONCLUSIONS: The anesthesia method (GA vs. RA) significantly influenced the early patterns of postoperative pain and opioid consumption after surgical treatment of a distal radial fracture, but neither total OEC over the first 3 postoperative days nor longer-term outcomes differed between the groups. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Swedish doctors choice of medical speciality and associations with cultural capital and perceived status: a cross-sectional study.

BACKGROUND: Many western countries have problems recruiting and retaining medical specialists. In Sweden there is a lack of primary care doctors and psychiatrists. Despite much research on the topic the shortage remains. We therefore set out to analyse choice of medical speciality using Bourdieu's theoretical concepts; cultural capital, social background and perceived status. METHODS: A cross-sectional questionnaire-based study of 399 alumni from the Medical School at Karolinska Institutet, Stockholm was performed. The response rate was 72% (n = 286); 262 of the respondents were in training to become specialists. Specialties were categorized as primary care, psychiatry, internal medicine, and surgical and hospital service specialties. To study the associations between medical specialties and cultural capital, we used multinomial regression analyses. Variables that showed a significant association with medical specialties were included in an adjusted multivariable model. These results were presented as odds ratios: the odds that a particular speciality is chosen in comparison to a choice of surgery as a speciality, based on perceptions of high status. RESULTS: The results were analysed using Bourdieu's theoretical concepts of cultural capital, in the form of educational capital and social prestige. We found distinctive differences in perceived status for the examined speciality groups, ranging from 70% high status for surgery down to 6% high status for geriatrics and primary care. Perceived status was also associated with respondents' own speciality choice, presented as an odds ratio. Our data did not show any associations between speciality choice and educational capital. We also included sociodemographic data. CONCLUSION: The field of medicine is according to Bourdieu an arena for power struggles. Knowledge of the distinctive differences in perceived status between medical specialties can be an asset particularly in relation to recruitment and retainment of specialist doctors. Our results could be used to identify specialities where perceptions of low status may be contributing to a shortage of specialists.

Nonoperative Treatment Compared with Volar Locking Plate Fixation for Dorsally Displaced Distal Radial Fractures in the Elderly: A Randomized Controlled Trial.

BACKGROUND: The usage of volar locking plate fixation for distal radial fractures has increased in older patient populations, despite the fact that surgical treatment in the elderly population has not clearly been proven to be superior to nonoperative treatment. The purpose of the present study was to compare nonoperative treatment with volar locking plate fixation with regard to clinical outcome for elderly patients with dorsally displaced distal radial fractures. METHODS: In this study, 140 patients were randomly allocated to nonoperative treatment with a plaster splint (n = 72) or volar locking plate fixation (n = 68). The outcome variables were the Patient-Rated Wrist Evaluation (PRWE) score, Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire score, EuroQol-5 Dimensions (EQ-5D) score, range of motion, grip strength, radiographic outcomes, and complications. Evaluation was performed at 3 and 12 months by unblinded observers. RESULTS: At 3 months, 122 patients were evaluated, and at 12 months, 119 patients were evaluated. At 3 months, the volar locking plate group, compared with the nonoperative treatment group, had a better median PRWE score (10.3 compared with 35.5 points; p = 0.002), DASH score (14.4 compared with 29.2 points; p = 0.016), and grip strength (71.0% of the uninjured hand compared with 53.9%; p < 0.001). Significant differences in favor of the volar locking plate group remained at 12 months; compared with the nonoperative treatment group, the volar locking plate group had a better median PRWE score (7.5 points compared with 17.5 points; p = 0.014), DASH score (8.3 points compared with 19.9 points; p = 0.028), and grip strength (96.8% compared with 80.0%; p = 0.001). Radiographic measurements favored volar locking plate fixation at 3 and 12 months. Complication rates were similar, with 11% major complications in the nonoperative group compared with 14% major complications in the volar locking plate group (p = 0.606) and 11% minor complications in the nonoperative group compared with 20% minor complications in the volar locking plate group (p = 0.197). CONCLUSIONS: The PRWE scores, DASH scores, and grip strength were better for the volar locking plate group compared with the nonoperative group at 3 and 12 months. The complication rates were similar. Our results imply that there is a benefit for the elderly patient with an unstable dorsally displaced distal radial fracture to be treated with a volar locking plate. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Quantifying cervical spondylosis: reliability testing of a coherent CT-based scoring system.

BACKGROUND: Grading of degeneration of the cervical spine is of great clinical value, considering the vast amount of radiological investigations that are being done with this query. Despite the fact that Computed Tomography (CT) is frequently used in clinical practice there is today no user-friendly and reliable scoring system for assessment of cervical spondylosis on CT-scans available. The aim of this study was to establish a scoring system for cervical spondylosis based on CT-scans and to test it for reliability. METHODS: Twenty adult patients undergoing CT of the cervical spine due to neck pain following a motor vehicle accident were included in the study. Three independent raters, i.e. one orthopedic surgeon and two radiologists, assessed their CT-scans. Two of the raters repeated the assessments after three months. A radiographic-based scoring system for cervical disc degeneration, addressing disc height, osteophytes and endplate sclerosis, was applied on CT and tested for reliability. A pre-existing, reliable CT-based scoring system for facet joint degeneration, considering joint space narrowing, osteophytes and irregularity of the articular surface was modified and reevaluated. This in order to develop a coherent CT-based total degeneration score for cervical spondylosis. RESULTS: The scoring systems for cervical disc degeneration and facet joint degeneration both exhibited an acceptable or better level of strength of agreement regarding intra- and interrater agreement. The total disc degeneration score showed a moderate level of inter-rater reliability with a kappa-value of 0.47 and a good intra-rater agreement with intra-class correlation coefficients (ICC) of 0.67 and 0.60 for the two raters performing the assessments. The total facet joint degeneration score showed a moderate level of inter-rater reliability (kappa 0.54) and an excellent intra-rater agreement with ICC 0.75 for one of the raters and fair for the other rater (ICC 0.54). When the total disc and facet joint degeneration score were classified into a three-point total degeneration score the inter-rater agreement was 0.695 and the ICC 0.82 and 0.73 respectively. CONCLUSIONS: This coherent scoring system assessing both disc degeneration and facet joint degeneration on CT-scans of the cervical spine was shown to meet the standards of reliability.

Stress among medical students during clinical courses: a longitudinal study using contextual activity sampling system.

OBJECTIVES: To investigate medical students' experiences of stress and other emotions related to their professional roles, as defined by the CanMEDS framework, by using the Contextual Activity Sampling System (CASS). METHODS: Ninety-eight medical students agreed to participate of whom 74 completed this longitudinal cohort study. Data was collected between 6th and 8th term via CASS methodology: A questionnaire was e-mailed to the participants every 3rd week(21questionnaires/measurements) during clinical rotations and scientific project work term. Emotions were measured by a 7-point Likert scale (e.g., maximum stress = 7). Answers were registered through mobile technology. We used a linear mixed-model regression approach to study the association between stress over time in relation to socio-demographic and learning activities related to CanMEDS roles. RESULTS: Participants completed 1390 questionnaires. Mean stress level over all time points was 3.6. Stress was reported as highest during the scientific project term. Learning activities related to 'Communicator,' 'Collaborator,' 'Scholar,' 'Manager' and 'Professional' were associated with increased stress, e.g. 'Scholar' increased stress with 0.5 points (t(1339)=3.91, p<0.001). A reduced level of stress was associated with 'Health Advocate' of 0.39 points (t(1338)=-2.15, p=0.03). No association between perceived stress and demographic factors, such as gender or age was found. CONCLUSIONS: An association between different learning activities related to CanMEDS Roles and feelings of stress were noted. The CASS methodology was found to be useful when observing learning experiences and might support educational development by identifying course activities linked to stress.

Swedish doctors' experiences and personality regarding medical specialty choice: a qualitative study.

OBJECTIVES: To explore an understanding of medical doctors' entire process of specialty choice with a focus on the influence of personal experiences and personality traits on choices made. METHODS: A qualitative study was performed. Semi-structured individual interviews were conducted with medical doctors undergoing their specialty training in Sweden about their experiences and personalities. The transcribed interviews were analyzed with an inductive content analysis approach. RESULTS: A total of 15 medical doctors participated. Three themes were identified using content analysis: To be invited or not, to fit in or not and to contribute or not. Furthermore, the results refute that specialty choice is a long-term, complex process. CONCLUSIONS: First, the importance of being invited to the specialty choice was stressed by the doctors, especially in their early years when they needed to feel valued and trusted. Secondly, the need to fit in was essential to make a sustainable career choice. Finally, the doctors' expressed a will to contribute to the medical field of their chosen specialty. The interviews showed that specialty choice is a long-term, complex process; therefore, one implication for the healthcare sector would be to target the entire chain of medical education to improve recruitment strategies for those specialties with recruitment difficulties. More studies are needed to understand better how positive and negative encounters within the healthcare sector can influence young doctors' specialty choice.

Factors influencing effectiveness in postgraduate medical education - a qualitative study of experiences of the responsible clinical consultants.

BACKGROUND: Medical education leaders are important for educational quality in postgraduate medical education. Their work tasks are complex and contain different components. However, factors that are influencing leaders´ effectiveness in completing these tasks are unexplored. Understanding and developing these factors is most likely essential to strengthen postgraduate medical education and to consequently improve the quality in health care delivery. This study explores the experiences of factors that influence effectiveness of clinical consultants responsible for postgraduate medical education at clinical departments. Effectiveness was defined as fulfillment of work tasks. METHODS: A qualitative study was performed with data gathered through semi-structured face-to-face interviews with 17 consultants responsible for postgraduate medical education. Data was analyzed by qualitative content analysis. RESULTS: Findings clustered into four themes of factors influencing effectiveness: individual (being an expert, social competence), relational (support and cooperation, communication), attitudinal (shared vision, organizational values, colleagues' attitudes) and structural (organizational characteristics, regulations and guidelines, conditions for the role). The factors were experienced to influence effectiveness in a positive or a negative direction. CONCLUSIONS: This study shed light on the complex and interrelated factors experienced to have impact on the role of consultant responsible for postgraduate medical education. Viewing the result through the concept of power, the role mainly relies on personal power sources like expert and referent power whereas power connected to the position often are lacking. To increase effectiveness of the role, a differentiated strategy which involves activities at both individual, group and organizational levels is needed.

External Fixation Versus Volar Locking Plate for Unstable Dorsally Displaced Distal Radius Fractures-A 3-Year Follow-Up of a Randomized Controlled Study.

PURPOSE: To determine if a volar locking plate (VLP) is superior to external fixation (EF) 3 years after surgery for unstable, dorsally displaced, distal radius fractures caused by low-energy injury in patients 50 to 74 years of age. METHODS: During 2009 to 2013, 140 patients with an unstable dorsally displaced distal radius fracture were randomized to either VLP or EF. One hundred eighteen patients (EF 56, VLP 62) were available for a 3-year follow-up. The primary outcome was the Disabilities of the Arm, Shoulder, and Hand (DASH) score at 3 years. Secondary outcomes were Patient-Related Wrist Evaluation (PRWE) score, EuroQol-5 Dimensions (EQ-5D) score, range of motion (ROM), grip strength, and radiological signs of osteoarthritis (OA) at 3 years. Moreover, reoperations and minor complications during the first 3 years were recorded. RESULTS: There were no differences regarding DASH, PRWE, EQ-5D, ROM or grip strength. The reoperation rate was 21% (13 of 62) in the VLP group compared with 14% (8 of 56) in the EF group. The OA rate was 42% (25 of 59) in the VLP group compared with 28% (15 of 53) in the EF group. CONCLUSIONS: Three years after surgery for unstable dorsally displaced distal radius fractures, the clinical and radiological results for VLP and EF were comparable. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Distal radius fractures-Regional variation in treatment regimens.

OBJECTIVES: After recent technical innovations of fracture surgery implants, treatment traditions are changing for distal radius fractures, the most common orthopaedic injury. The aim of this study was to determine if the choice of surgical method for treatment of distal radius fractures differ between healthcare regions in Sweden. METHOD: The study was based on all (n = 22 378) adult patients who were registered with a surgical procedure due to a distal radius fracture during 2010-2013 in Sweden. Consecutive data was collected from the Swedish National Patient Registry. RESULTS: The proportions of use of surgical method varied among the 21 healthcare regions between 41% and 95% for internal fixation, between 2.3% and 44% for percutaneous fixation and between 0.6% and 19% for external fixation. Differences between regions were statistically significant in all but 6 comparisons when controlled for age and gender. Incidence rates of surgical treatment of a distal radius fracture varied between 4.2 and 9.2/10 000 person-years. CONCLUSION: We conclude that there is a large variation in operative management of distal radius fractures between Swedish healthcare regions.