Effect of individualized communication skills training on physicians' discussion of clinical trials in oncology: results from a randomized controlled trial.

BACKGROUND: Discussing randomized clinical trials (RCTs) with cancer patients is one of the most challenging communication tasks a physician faces. Only two prior Communication Skills Trainings (CSTs) focused on RCTs in oncology have been reported. Their results demonstrated the need for further improvement. We developed and evaluated an enhanced, individually-tailored CST focused on improving physicians' communication during discussions of RCTs. METHODS: The CST focused on personal learning goals derived from video pre-assessment that were addressed in a 1.5-day group workshop and one-on-one coaching sessions. Forty physicians were recruited and randomly assigned to intervention and control groups. Video-recorded standardized consultations with actor-patients were utilized. As a primary outcome (1), training success was evaluated by blinded raters using a previously developed checklist. Change in checklist items was evaluated between pre- and post-training assessment and compared against control group results. As a secondary outcome (2), the physicians' feeling of confidence was assessed by a questionnaire. RESULTS: (1) Significant improvements in the intervention group were observed for the score on all items (p = 0.03), for the subgroup of content-specific items (p = 0.02), and for the global rating of communication competence (p = 0.04). The improvement observed for the subgroup of general communication skill items did not achieve significance (p = 0.20). (2) The feeling of confidence improved in nine out of ten domains. CONCLUSION: While the individually-tailored CST program significantly improved the physicians' discussions of RCTs, specifically related to discussion content, what remains unknown is the influence of such programs in practice on participant recruitment rates. The study was registered retrospectively in 2010/07/22 under DRKS-ID: DRKS00000492 .

Body image after heart transplantation compared to mechanical aortic valve insertion.

OBJECTIVE: Heart transplantation (HT) obviously affects body image and integrity. However, there are very few empirical data post-transplant. METHODS: In a cross-sectional study, 57 HT patients were compared with 47 subjects with mechanical aortic valve replacement (AVR) using the Dresden-Body-Image questionnaire (DKB) and specific questions regarding integration of the organ/device. In addition, affective symptoms and quality of life (QoL) were assessed (12-Item Short-Form Health Survey and Hospital Anxiety and Depression Scale, HADS). RESULTS: DKB-35 scores did not differ. HT patients scored higher than AVR on specific questions regarding integration of the organ/device. AVR patients showed more affective disturbance and lower mental QoL than HT subjects. Affective scores correlated negatively with body image scores. Seventeen percent of all patients showed psychological distress (HADS scores >8). CONCLUSIONS: HT patients integrated the new organ well - and even better than AVR subjects did with the device. In general, our data corroborate a good adaptation process, in particular in HT patients. Similar to other reported data, a subgroup of 15-20% of patients shows stronger mental distress, including body image problems. These must be identified and treated by professionals. Patients with AVR deserve more attention in the future.

Self-perspective leads to increased activation of pain processing brain regions in fibromyalgia.

BACKGROUND: Dysfunction of central nervous pain processing is assumed to play a key role in primary fibromyalgia (FM) syndrome. This pilot study examined differences of pain processing associated with adopting different interpersonal perspectives. METHODS: Eleven FM patients and 11 healthy controls (HC) were scanned with functional magnetic resonance imaging. Participants were trained to take either a self-perspective or another person's perspective when viewing the visual stimuli. Stimuli showed body parts in painful situations of varying intensity (low, medium, and high) and visually similar but neutral situations. RESULTS: Patients with FM showed a higher increase in blood oxygen level dependent (BOLD) response, particularly in the supplementary motor area (SMA). All pain-related regions of interest (anterior insula, somatosensory cortices, anterior cingulate cortex, and SMA) showed stronger modulation of BOLD responses in FM patients in the self-perspective. In contrast to pain processing regions, perspective-related regions (e.g. temporoparietal junction) did not differ between FM and HC. CONCLUSIONS: The stronger response of all four pain processing cerebral regions during self-perspective is discussed in the light of disturbed bottom-up processing. Furthermore, the results confirm earlier reports of augmented pain processing in FM, and provide evidence for sensitization of central nervous pain processing.

Sense of coherence contributes to physical and mental health in general hospital patients in China.

The sense of coherence (SOC) may explain why some people become ill under stress whereas others remain healthy. SOC is strongly related to perceived health, particularly mental health. Little is known about the physical and mental health statuses associated with SOC among general hospital outpatients in China. This multicentre cross-sectional study analysed 491 outpatients from four large Chinese general hospitals located in Beijing, Shanghai, Chengdu and Kunming. Patients completed questionnaires examining their SOC (SOC-9), somatic symptom severity (PHQ-15), depression (PHQ-9), generalised anxiety disorder (GAD), health anxiety (WI-7), quality of life (QoL; SF-12) and socio-demographic and clinical characteristics. SOC was negatively correlated with daily-life impairment, symptom duration, somatic symptom severity, depression, GAD and health anxiety, but was positively correlated with age as well as physical and mental QoL. Using a multiple linear regression model, the three strongest correlates of SOC were mental QoL, depression and age. These three variables explained 52% of the variance. SOC may be an important contributor to both mental and physical health in Chinese general hospital outpatients, which is consistent with the results obtained for primary care patients in Western countries. Longitudinal studies are needed to investigate how SOC predicts physical and mental health statuses over time and how these statuses respond to treatment for low SOC.

Differentiating cerebral ischemia from functional neurological symptom disorder: a psychosomatic perspective.

BACKGROUND: The differential diagnosis of pseudo-neurological symptoms often represents a clinical challenge. The Diagnostic and Statistical Manual of Mental Disorders, DSM-5, made an attempt to improve diagnostic criteria of conversion disorder (functional neurological symptom disorder). Incongruences of the neurological examination, i.e. positive neurological signs, indicate a new approach--whereas psychological factors are not necessary anymore. As the DSM-5 will influence the International Classification of Diseases, ICD-11, this is of importance. In the case presented, a history of psychological distress and adverse childhood experiences coexisted with a true neurological disorder. We discuss the relevance of an interdisciplinary assessment and of operationalized diagnostic criteria. CASE PRESENTATION: A 32-year-old man presented twice with neurological symptoms without obvious pathological organic findings. A conversion disorder was considered early on at the second admission by the neurology team. Sticking to ICD-10, this diagnosis was not supported by a specialist for psychosomatic medicine, due to missing hints of concurrent psychological distress in temporal association with neurological symptoms. Further investigations then revealed a deep vein thrombosis (though D-dimers had been negative), which had probably resulted in a crossed embolus. CONCLUSION: The absence of a clear proof of biological dysfunction underlying neurological symptoms should not lead automatically to the diagnosis of a conversion disorder. In contrast, at least in more complex patients, the work-up should include repeated psychological and neurological assessments in close collaboration. According to ICD-10 positive signs of concurrent psychological distress are required, while DSM-5 emphasizes an incongruity between neurological symptoms and neurophysiological patterns of dysfunction. In the case presented, an extensive medical work-up was initially negative, and neither positive psychological nor positive neurological criteria could be identified. We conclude, that, even in times of more sophisticated operationalization of diagnostic criteria, the interdisciplinary assessment has to be based on an individual evaluation of all neurological and psychosocial findings. Prospective studies of inter-rater reliability and validity of psychological factors and positive neurological signs are needed, as evidence for both is limited. With respect to ICD-11, we suggest that positive neurological as well as psychological signs for functional neurological symptom disorder should be considered to increase diagnostic certainty.

A manual-based group program to improve mental health: what kind of teachers are interested and who stands to benefit from this program?

PURPOSE: In order to evaluate a manual-based group program for teachers aiming at strengthening mental health, we examined (1) whether the teachers interested in participating differ from their colleagues without interest and (2) whether there is evidence of subgroups benefiting more than others among those who participated. METHODS: Out of a basic sample of 949 schoolteachers, 337 teachers declared interest in a group program. All teachers were surveyed with the "General Health Questionnaire", the "Maslach Burnout Inventory" and the "Effort Reward Imbalance Questionnaire". In addition, participating teachers were screened with the "Symptom Checklist 27" T and χ(2)-tests were calculated to detect differences between those interested in the program and the remaining 612 teachers. Six factors were established and used for a regression analysis that identified specific parameters more or less correlating with health benefits of those who participated in the program. RESULTS: Findings showed that those declaring interest in the intervention displayed a higher degree of occupational stress according to all health parameters examined. Teachers interested in the program were significantly younger, more frequently female and single. The regression analysis showed that the baseline scores of the six health parameters were the strongest predictors for improvement. Worse scores before the beginning of the intervention correlated with a more positive effect. CONCLUSIONS: Intervention programs aiming at alleviating the mental stress of teachers find the interest of those who need it most. More importantly, the latter are the ones who--at least if our program is applied-benefit best.

Breaking bad news in China--the dilemma of patients' autonomy and traditional norms. A first communication skills training for Chinese oncologists and caretakers.

OBJECTIVE: Current practice of breaking bad news in China involves disclosure of information first to family members who then decide whether the patient should receive this information. Recently, however, patients' right to be informed has been regulated by law. This represents a dilemma for oncologists who now have to balance traditional practice with new legal requirements. A communication skills training (CST) was developed for Chinese practice. It addresses this issue and may help participants find individual solutions within these conflicting requirements. METHODS: A first CST about breaking bad news took place at the Beijing Cancer Hospital, China, with 31 participants. We (i) assessed current practice, (ii) evaluated the workshop and (iii) self-assessed performance ratings about breaking bad news before and after the workshop with the help of questionnaires. RESULTS: (i) Participants stated that in most cases (78%), they inform family members first. Contrary to this practice, participants think that about 75% of patients would like to be informed first, independent of family. (ii) Overall, the workshop received a very good rating (M = 1.2; scale between 1 and 6). (iii) After the workshop, the participants rated their performance significantly higher in all areas, for example, talking about diagnosis, prognosis and death with the patient and the family. CONCLUSIONS: The CST showed high acceptance and led to significantly improved performance ratings of participating physicians in many areas. It helped participants deal with conflicting demands. For future trainings, further socio-cultural adaptations are needed. Obvious conflicts still exist and need to be resolved.

Burnout and effort-reward imbalance improvement for teachers by a manual-based group program.

OBJECTIVE: We developed a manual-based psychological group program aimed at teachers and focussing on their professional relationships. The intervention comprised ten sessions over a 10-month period. The aim of the program was to strengthen teachers' health. We investigated whether the effects of our intervention, during which the MBI and ERI were applied, result in general alleviation of occupational stress experienced by teachers. METHODS: This is a randomized controlled trial. All teachers (N = 2,484) of two school types (grammar schools and secondary modern schools) in 3 districts of southwestern Germany were invited to take part in our program. All teachers declaring their interest (N = 337) in the intervention were included in the project. They were randomly assigned to either the intervention group (N = 171) or to the control group (N = 166). RESULTS: We found that teachers who participated in at least 50% of the program benefited from this short intervention. Significant improvement was achieved on the two MBI scales, Emotional Exhaustion and Personal Accomplishment, as well as on the ERI subscale Appreciation. CONCLUSION: Teachers' occupational stress level may be decreased by taking part in a short manual-based psychological group intervention that focuses on more effective handling of interpersonal problems in school. Therefore, teachers should receive support and guidance in developing the appropriate skills necessary to cope with stress appropriately.

Mental health and patterns of work-related coping behaviour in a German sample of student teachers: a cross-sectional study.

PURPOSE: The aim of this cross-sectional study was to evaluate the mental health of student teachers, to analyse the extent to which they feel prepared for their profession by the university curriculum and to investigate patterns of coping with occupational stress. METHODS: A sample of 481 German student teachers was investigated using two standardised instruments: GHQ-12 (General Health Questionnaire) and AVEM (Arbeitsbezogenes Verhaltens- und Erlebensmuster), an occupational stress and coping questionnaire describing four patterns of work-related coping behaviour. In addition, we asked how well the student teachers felt that the curriculum prepared them for their profession. RESULTS: Forty-four per cent of the student teachers report impaired mental health in the second teacher training period, indicated by a GHQ value equal to or over the cut-off of four. The AVEM responses revealed more than 40% showing risk patterns (A or B) compared to only 26.3% displaying a healthy coping style (G), while 32.8% demonstrate an unambitious style (S). These GHQ values are inversely correlated with the extent to which student teachers feel prepared for their work by the university curriculum. CONCLUSIONS: Our data indicate a problematic stress level for student teachers in the second training phase (high exposure to health risks and unfavourable coping styles). Since teaching is clearly an extremely demanding job, it is vital that teacher training systems contribute towards protecting the health of teachers by focusing on fostering healthy personal attitudes and equipping young teachers with coping styles and skills that will better prepare them for the challenges facing them in their daily work. Self-care health management should also be part of the teacher training curriculum.

Emotional perception in patients with eating disorders in comparison with depressed patients.

OBJECTIVE: Emotion regulation is a key issue for many psychiatric and psychosomatic disorders, including eating disorders. Eating disordered patients (EDP) show high levels of depressive comorbidity, and there is much uncertainty about disorder-specific deficits. This study is aimed at delineating disorder-specific disturbances of emotional perception in EDP. METHOD: Fifty-two EDP were compared with 35 depressed patients (DP) and 25 healthy controls. They rated their emotional experience when viewing visual emotional stimuli. Emphasis was placed on the patients' perception of their own emotions and not on the recognition of emotions in others. Severity of depression was assessed by the Beck Depression Inventory. RESULTS: Eating disordered patients and DP reported less anger than healthy controls-independent of the severity of depression. In addition, DP showed increased levels of disgust when confronted with anger stimuli. Happiness was rated less in EDP and DP, which was associated with severity of depression. There were no differences between the EDP subgroups bulimia nervosa and anorexia nervosa. CONCLUSION: Eating disordered patients and DP showed alterations of emotional perception of anger, an emotion which is closely linked to interpersonal difficulties. Alterations in emotional perception of EDP and DP might be due to more general emotion regulation disturbances. In order to detect more subtle differences between psychiatric subgroups, more sophisticated investigation tools are needed. Increased disgust ratings in DP merit further investigation.

[Psychosomatic basic care in the general hospital - an empirical investigation of the bio-psycho-social stress, treatment procedures and treatment outcomes from the vantage point of medical doctors]. / Psychosomatische Grundversorgung im Krankenhaus-Eine empirische Untersuchung zu biopsychosozialen Belastungen, Behandlungsmaßnahmen und Behandlungsergebnissen aus Sicht der Arzte.

OBJECTIVES: The present study investigates the psycho-social stress, the treatment procedures and the treatment outcomes of stressed patients in the hospital from the perspective of the hospital doctors. METHODS: Physicians from all disciplines who had completed the course "Psychosomatic Basic Care" as part of their specialist training documented selected treatment cases. RESULTS: 2,028 documented treatment cases of 367 physicians were evaluated. Anxiety, depression and family problems were the most common causes of psychosocial stress. In over 40 % of the cases no information was found on the medical history. Diagnostic and therapeutic conversations took place with almost half the patients (45%). From the vantage point of the physicians patients receiving diagnostic and therapeutic conversations achieved significantly more positive scores with respect to outcome variables than patients without these measures. Collegial counseling was desired for more than half of the patients and took place mainly among the ward team. There were few significant differences in the views of surgical and nonsurgical physicians. CONCLUSIONS: Psychosomatic basic care in general hospitals is possible, albeit with some limitations. Patients undergoing psychosocial interventions have better treatment outcomes. Therefore, extending training to 80 hours for all medical disciplines seems reasonable.

Stressful involvement in psychotherapeutic work: therapist, client and process correlates.

We examined potential predictors of therapists' "Stressful Involvement" (SI) among variables reflecting the psychotherapy process, therapist characteristics, patients' symptom severity or context variables (treatment setting). Ninety-eight sequences from individual psychodynamic treatments conducted by 26 therapists were studied. Data were analyzed using mixed regression models. Between-therapist and within-therapist variance accounted for most of the difference in SI. SI was strongly associated with negative feelings of the therapist about patient and therapy in the time between sessions. Therapists with more 'unassertive' and 'vindictive' interpersonal styles were also more prone to experiencing SI. The strong association of SI with therapist rather than patient characteristics and process ratings indicates the importance of further study of the therapist as a person and participant in psychotherapy.

Symptom presentation, interventions, and outcome of emotionally-distressed patients in primary care.

BACKGROUND: Patients with psychosocial problems often present somatic symptoms in primary care. OBJECTIVE: The authors compare interventions and outcomes of emotionally-distressed patients by presenting physical disease, somatoform symptoms, or psychological symptoms. METHOD: General practitioners (N=191) documented data from 1,286 patients with psychosocial problems. Experts rated the presented reasons for encounter. RESULTS: Somatoform symptoms, as well as physical disease, result in patients' receiving physical treatments. Psychologically-oriented treatment is more likely with psychological presentation, but not significantly related to somatoform symptoms. CONCLUSION: These findings underline the importance of a specific treatment approach for patients with somatoform symptoms, so as to avoid inappropriate treatment.

Addressing the transition from curative to palliative care: concept and acceptance of a specific communication skills training for physicians in oncology--COM-ON-p.

BACKGROUND: There are several reasons why consultations addressing the transition to palliative care are especially challenging, and physicians are generally not very well prepared to meet these challenges. We therefore conceptualized and evaluated a concise, individualized communication skills training (CST) addressing i) communication concerning the transition to palliative care, and ii) involvement of significant others in the conversation. Core aspects of the CST and data of acceptance will be presented. METHODS: The core elements of the CST are a 1.5-day workshop held in small groups and a subsequent individual coaching session during everyday routine. The workshop is practice-oriented and highly individualized. Acceptance was assessed by using a self-developed 13-item questionnaire. RESULTS: All 41 participating physicians completed the evaluation questionnaire. The participants' overall evaluation of the workshop was very positive and indicated a high personal benefit. Individualized learning tools like 'assessment of individual learning goals' and 'closing with individual take-home messages' were also seen as positive, but not as positive as other elements like practicing with actor patients and feedback from actors and facilitators. CONCLUSIONS: The presented specific, individualized, and concise CST is well accepted, and physicians see a high practical relevance and strong personal benefits.

[Psychotherapy by medical doctors in primary care: an empirical investigation in South Baden, Germany]. / Arztliche Psychotherapie in der Haus--und Facharztpraxis: Eine empirische Untersuchung in südbaden.

OBJECTIVES: The present study investigates the kind and frequency of medical psychotherapy carried out in GPs' offices in South Baden, Germany. METHODS: Established GPs and other primary-care physicians from South Baden (n = 64) who had successfully completed additional training in psychotherapy were queried about their current psychotherapeutical services using a questionnaire. The data were evaluated by applying descriptive and correlative statistical procedures. RESULTS: The response rate was 93.8 % (n = 60). Standard psychotherapy short-term psychotherapies with up to 25 hours and long-term psychotherapies with up to 50 hours) had been supplied, with an average of 8.3 patients per doctor and quarter. Services rendered outside standard psychotherapy regimen including the approved services for basic psychosomatic care, especially short-term psychotherapeutic interventions of up to ten sessions, were performed with an average of 108.9 patients per doctor. As predictors for the performance of these services we found (1) patients with a high educational level (p = 0.002), (2) the cooperation with other psychosocial professional groups (p = 0.008), and (3) the participation in quality-assurance measurements (p = 0.009). CONCLUSIONS: Physicians with additional training in psychotherapy offered a great amount of psychotherapeutical services not covered by the the standard psychotherapy guidelines of the national health services. These offers, borne primarily by idealism, should be acknowledged by new reward models in the future.

Inpatient versus day clinic treatment for bulimia nervosa: a randomized trial.

BACKGROUND: In bulimia nervosa, more intense treatments are recommended if outpatient treatment fails. This is the first randomized controlled trial comparing the options of inpatient versus day clinic treatment. METHOD: Patients with severe bulimia nervosa were randomly assigned to inpatient or day clinic treatment of similar length and intensity. Specific and general psychopathology was assessed at the end of treatment and a 3-month follow-up. RESULTS: Fifty-five patients were randomized; 22 day clinic patients and 21 inpatients started the program. At the end of treatment, a significant reduction of general and specific pathology was found in both settings. Following discharge, there was more deterioration in bulimic symptoms after inpatient treatment, but overall, results were comparable. CONCLUSIONS: Inpatient and day clinic programs are effective treatments for severely disturbed bulimic patients with similar results at the 3-month follow-up. Further follow-up will show if a higher instability of results after inpatient treatment is of importance in the long term.

Emotional perception in eating disorders.

OBJECTIVE: It remains an open question whether there are basic emotional perception and emotional processing deficits in eating disorders (ED). The aim of this study was to explore deficits in emotional perception in restrictive anorexia nervosa (AN-R) and bulimia nervosa (BN), using visual emotional stimuli. METHOD: Thirty-four patients with ED (19 with BN and 15 with AN-R) were compared with 25 controls. Visual stimuli from the international affective picture system were used. RESULTS: Patients with AN-R showed increased fear when confronted with stimuli containing anger, whereas patients with BN showed a tendency towards decreased fear. There were no other fundamental differences in the emotional perception of fear, happiness, sadness, and anger. DISCUSSION: The finding of increased fear when exposed to the emotion of anger might be attributed to introversion and conflict avoidance of anorectic patients. No other basic deficiency of emotional perception was found.

[Treatment components of inpatient and day clinic treatment of anorexia nervosa: the patient's perspective]. / Stationäre und tagesklinische Behandlung der Anorexia nervosa: Bewertung von Therapiekomponenten aus Patientensicht.

The acceptance of a treatment depends on what patients experience as helpful or not. In the treatment of anorexia nervosa, the patient's perspective is of special importance as patients are typically highly ambivalent concerning a change in their dysfunctional attitudes and behaviour. 102 patients with anorexia nervosa (ICD-10) evaluated the components of a complex, multimodal treatment programme (inpatient and day clinic) at the end of therapy or follow-up. Overall, psychodynamic as well as symptom-oriented treatment components were experienced as "helpful". Psychodynamic individual sessions received the best assessments. Individual sessions got higher ratings than group sessions. Patients with less successful outcomes described symptom oriented elements like weight goals and work on eating behaviour as significantly less helpful. Lower rankings of some symptom oriented components were associated with more overall symptom severity and bulimic pathology and may point to a feeling of being overtaxed with the programme or a lack of motivation to change.

A Cross-Cultural Comparison of Climacteric Symptoms, Health-Seeking Behavior, and Attitudes towards Menopause Among Mosuo Women and Han Chinese Women in Yunnan, China.

Cultural *YZ and XZ contributed equally. background has been shown to influence climacteric symptoms of women. This study compares various characteristics of climacteric symptoms, illness conception, health-seeking behavior, and attitude towards menopause of Mosuo women, a Chinese ethnic minority with a matriarchal structure, and Han Chinese women, the majority ethnic group of China with a patriarchal structure. Through convenience sampling, 51 Mosuo and 47 Han women ages 40 to 60 completed a sociodemographic questionnaire, the modified Kupperman Menopause Index (KMI), the Self-Rating Scale of Illness Conception and Health Seeking Behavior (SSICHSB) and the Menopause Attitude Questionnaire (MAQ). The Mosuo and Han Chinese women are comparable with regard to their age, educational levels and menstrual status. During climacteric, Mosuo women showed less severe melancholia ( p = .009), reported less health-seeking behavior ( p = .009), and displayed more positive attitudes towards menopause than their Han Chinese counterparts ( p < .001). One predictive variable of the melancholia severity in Mosuo was "menarche age", while that in the Han group was "social view on the menopause". Future research with a larger sample is needed to deepen our understanding about the interaction between culture and climacteric symptoms.

Psychosocial health risk factors and resources of medical students and physicians: a cross-sectional study.

BACKGROUND: Epidemiological data indicate elevated psychosocial health risks for physicians, e. g., burnout, depression, marital disturbances, alcohol and substance abuse, and suicide. The purpose of this study was to identify psychosocial health resources and risk factors in profession-related behaviour and experience patterns of medical students and physicians that may serve as a basis for appropriate health promoting interventions. METHODS: The questionnaire -Related Behaviour and Experience "Work administered in cross-sectional surveys to students in the first (n = 475) and in the fifth year of studies (n = 355) in required courses at three German universities and to physicians in early professional life in the vicinity of these universities (n = 381). RESULTS: Scores reflecting a healthy behaviour pattern were less likely in physicians (16.7%) compared to 5th year (26.0%) and 1st year students (35.1%) while scores representing unambitious and resigned patterns were more common among physicians (43.4% vs. 24.4% vs. 41.0% and 27.3% vs. 17.2% vs. 23.3 respectively). Female and male responders differed in the domains professional commitment, resistance to stress and emotional well-being. Female physicians on average scored higher in the dimensions resignation tendencies, satisfaction with life and experience of social support, and lower in career ambition. CONCLUSION: The results show distinct psychosocial stress patterns among medical students and physicians. Health promotion and prevention of psychosocial symptoms and impairments should be integrated as a required part of the medical curriculum and be considered an important issue during the further training of physicians.