[How to Motivate Medical Students to Practice in Rural Areas]. / Wege aufs Land ­ Wie Medizinstudierende für die Tätigkeit im ländlichen Raum gewonnen werden.

BACKGROUND: The excellent project "LandArztMacher" is an attempt to work against the predicted shortage of rural doctors in Germany with diverse approaches. METHOD: "LandArztMacher" is a clinical traineeship with four weeks of practical training in general practices and clinics in the Bavarian countryside, accompanied by joint professional teaching. Participants were asked before and after the internship about the topics "importance of an internship in rural areas"; "attractiveness of rural areas" (scale: 0/no agreement to 10/full agreement). Ideas about the tasks of a general practitioner were assessed (scale: 0/no idea at all to 100/exact idea). The present study is a repeated cross-sectional study. The median is reported as the location measure and the interquartile range as the dispersion measure. RESULTS: Participants (n=363, 74% female, n=267, age: range 19-46 years, mean: 23.2 years, SD: 2.41 years) from the clinical section of the medical studies considered an internship in the rural area before and after the internship very important (median: 8 and 9, respectively) and could well imagine working in the countryside (median: 7 and 8, respectively). Their attitude towards the cultural offerings or the infrastructure did not change (median: 6 in each case). After the internship, the students had a more precise idea of what a general practitioner tasks are (median: 65 and 90, respectively). SUMMARY: A well-structured four-week rural internship can enhance the appeal of future rural employment through individual supervision and collaborative training.

24-Months Cluster-Randomized Intervention Trial of a Targeted Fall Prevention Program in a Primary Care Setting.

BACKGROUND: Falls and fall-related injuries are common in community-dwelling older persons. Longitudinal data on effective fall prevention programs are rare. OBJECTIVE: Therefore, we evaluated a 4-months multi-component exercise fall prevention program in a primary care setting on long-term effects over 24 months on falls and concomitant injuries in older community-dwelling persons with high risk of falling. DESIGN AND SETTING: In the Prevention of Falls (PreFalls) study, forty general practitioners in Germany were cluster-randomized (1:1) into an intervention group (IG) or control group (CG). Three hundred seventy-eight independently living people with high risk of falling (78.1 ± 5.9 years, 75% women) were assigned to IG (n = 222) or CG (n = 156). INTERVENTION AND MEASUREMENTS: Patients in IG took part in a 4-months multi-component exercise program comprising strength and balance exercises (28 sessions); patients in CG received no intervention. Primary outcome measure was number of falls over 24 months, analyzed by a patient-level, linear mixed Poisson model. Secondary endpoints were number of fall-related injuries, changes in physical function, fear of falling, and mortality. RESULTS: After 24 months, the IG demonstrated significantly fewer falls (IRR = 0.63, p = 0.021), injurious falls (IRR = 0.69, p = 0.034), and less fear of falling (p = 0.005). The mortality rate was 5.0% in IG and 10.3% in CG (HR = 0.51, 95% CI: 0.24 to 1.12; p = 0.094). CONCLUSIONS: In older community-dwelling persons with high risk of falling, a short-term multi-component exercise intervention reduced falls and injurious falls, as well as fear of falling over 24 months.

[A Successful Strategy against the Expected Shortage of Physicians in Rural Areas]. / Gute Ärzte braucht das Land ­ eine erfolgreiche Strategie wider den drohenden Landärztemangel.

BACKGROUND: The expected shortage of physicians in rural areas of Germany calls for strategies to prevent an under-supply of care for patients living in such areas. OBJECTIVES: The innovative care project "Good Physicians are needed for the Countryside" is a multi-modal concept comprising 29 components implemented in an economically deprived area, aiming to attract young physicians to work in rural areas on a long-term basis. RESULTS: 5 physicians in training were hired during the project phase, and a further 3 after the project had ended. 2 of these now own and run one of the cooperating practices. Project components facilitating learning across generations was considered especially important;13 of 29 project components (45%) were judged to be very important by participants. CONCLUSIONS: It is possible to motivate medical doctors and their families to work in the countryside by providing targeted individual professional and personal counselling, which requires limited organizational capacity but considerable commitment of staff time.

[Health Assistants Perspectives on Team-Led Program for Patients with Panic Disorder in General Practice - A Qualitative Study]. / Perspektiven von Medizinischen Fachangestellten zu teambasierter Behandlung von Patienten mit Panikstörung in der Hausarztpraxis ­ Eine qualitative Studie.

AIM OF THE STUDY: Investigation of the perspective of medical assistants (MA) regarding their participation in behaviour-therapy oriented interventions in family practice. METHOD: 15 MA (w, 39.5 years old), case managers in a general practitioner supported exercise programme for patients with panic disorder (ICD-10: F41.0), were interviewed using semi-structured interview guidelines on the recruitment and interaction of/with patients, communication of the exercises and implementation in everyday practice. The interviews (n = 14) were documented, transcribed and qualitatively analysed according to Mayring. RESULTS: MA perceived their contribution to the intervention regarding recruitment and monitoring of patients through telephone contacts as positive. CONCLUSION: Strengthening the role of MAs' can help to provide targeted support for patients with mental health problems in GP care as part of a low-threshold intervention and relieve the workload on the GP.

Evaluation of Interdisciplinary Emergency Ultrasound Workshop for Primary Care Physicians in Nepal.

PURPOSE: Point-of-care ultrasound (POCUS) is a quick bedside tool that has the potential to improve emergency care in resource-limited settings due to its relatively low cost and accessibility. Effort to disseminate the knowledge and skills about POCUS is inadequate in low and middle income countries like Nepal. We conducted a two-day interdisciplinary advanced emergency ultrasound workshop that targeted physicians working in emergency department and primary care, especially in rural Nepal. We explored the effectiveness of this training based on validated Kirkpatrick's 4 steps of evaluating training outcomes. MATERIALS AND METHODS: We conducted a prospective quasi-experimental study with mixed research design. Multidisciplinary physicians working in emergency departments participated in the two-day workshop. We assessed and compared the pre- and post-workshop knowledge. We collected on-site and a follow-up feedback to explore pre- and post-workshop confidence level, perceived usefulness and clinical use of ultrasound using a 5-point Likert scale. The barriers to use POCUS were explored. RESULTS: A total of 50 physicians from different parts of Nepal participated in the workshop. The academic level of the participants, duration of their clinical experience and the previous use of POCUS did not have a significant difference in their pre- and posttest knowledge scores. The difference between the median (IQR) pre- and posttest scores [14 (12.75-17.75) and 24.5 (22.25-25.5), respectively] was statistically significant (p<0.001). Perceived confidence level and usefulness of the POCUS increased significantly in all of its domains (p<0.001). Self-reported increase in its clinical use was significant (p<0.001) for all fields. CONCLUSION: The participation in this emergency ultrasound workshop increased the knowledge of participants in POCUS. Their confidence, perceived usefulness and clinical use of POCUS improved significantly. Objective longitudinal follow-up of participants' skill and demonstration of increased clinical use of POCUS in emergency department influencing the clinical outcome would be the focus of future research.

[Panic disorder and agoraphobia in general practice: Advantages and pitfalls of a practice team-supported exposure training from the general practitioner's perspective - a qualitative study]. / Panikstörung und Agoraphobie hausärztlich behandelt: Vorzüge und Fallstricke eines Praxisteam-unterstützten Expositionstrainings aus Sicht von Hausärztinnen und Hausärzten ­ eine qualitative Studie.

INTRODUCTION: For the treatment of anxiety disorders behavior therapy-oriented methods are recommended for primary care as well. Within the trial "Jena-PARADISE" a primary care practice team-supported exposure training for patients with panic disorder with or without agoraphobia was developed and evaluated. The present paper gives an overview of general practitioners' subjective views on the practicability, feasibility and effectiveness of this new intervention for both patients and GP teams. METHODS: Questions were operationalized based on Bellg's intervention fidelity framework. Fourteen GPs of the intervention group were sampled purposefully and interviewed in a semi-structured way. Generated data were analyzed following Mayring's content analysis approach. RESULTS: The treatment program was positively assessed among the GPs and seen as a useful therapeutic option for inadequately treated patients. The therapy elements 'psycho-education' and 'interoceptive exposure exercises' were described as feasible, while situational exercises and relapse prevention got a less positive rating. The active participation of the nurse in the treatment program was seen as supportive. CONCLUSION: From the GP perspective, the treatment program for patients with panic disorder and/or agoraphobia seems to be a viable therapeutic option in primary care.

[Well informed? Survey results on individual out-of-pocket health services in selected GP practices]. / Gut beraten? Ergebnisse einer Umfrage zu Individuellen Gesundheitsleistungen in ausgewählten Hausarztpraxen.

OBJECTIVES: Patients have to pay out of their own pocket for individual medical services (in German: Individuelle Gesundheitsleistungen, IGeL). The benefit of many IGeL is controversial. Hence, well-founded patient information and counselling are important. For this purpose, several medical organizations and associations developed a checklist including 10 criteria concerning legal and content aspects. Based on this checklist, this study examined how well patients feel informed about IGeL by their doctors. Additionally, we assessed the utilization of IGeL and the attitude of physicians towards IGeL. METHODS: A questionnaire was distributed to 1,000 patients in 20 GP practices in Germany. The data of the patient survey was analyzed descriptively. RESULTS: The response rate to the patient survey was 92.9 %. Of 923 patients, 38 % used at least one IGeL in the last 12 months. The most common IGeL were ultrasound examinations (34 %). Differences were found in compliance with the criteria checklist: In most cases, patients received an invoice (79 %), ad-free information (70 %) and explanations of the medical necessity of the IGeL (70 %). However, physicians have failed to meet these criteria in more than a fifth of respondents. Also, physicians rarely refer to other requirements of the checklist such as, for example, further information and the possibility of obtaining a second opinion. CONCLUSION: This non-representative survey indicates that many patients make use of IGeL. However, they are often not well advised. Physicians should consider criteria of the checklist more rigorously.

[The Jena Anxiety Monitoring List (JAMoL) - a tool for the evidence-based treatment of panic disorder with or without agoraphobia in primary care]. / Die Jena Angst-Monitoring-Liste (JAMoL) - ein Instrument zur evidenzbasierten Behandlung von Panikstörung mit oder ohne Agoraphobie in der Hausarztpraxis.

BACKGROUND: Behavior therapy-oriented methods are recommended for treating anxiety disorders in primary care. The treatment of patients with long-term conditions can be improved by case management and structured clinical monitoring. The present paper describes the rationale, design and application of the 'Jena Anxiety Monitoring List' (JAMoL), a monitoring tool for the treatment of patients with panic disorder, with or without agoraphobia, in primary care. METHODS: JAMoL's design was based on established clinical measures, the rationale of exposure-based anxiety treatment, and research on family practice-based case management. After piloting, the JAMoL was used in the clinical study 'Jena-PARADISE' (ISRCTN64669297), where non-physician practice staff monitored patients with panic disorder by telephone. Using semi-structured interviews in concomitant studies, study participants were asked about the instrument's functionality. RESULTS: The JAMoL assesses the severity of anxiety symptoms (6 items) as well as the patient's adherence to therapy (4 items) and fosters the case management-related information exchange (3 items). An integrated traffic light scheme facilitates the evaluation of monitoring results. Within the clinical study, non-physician practice staff carried out a total of 1,525 JAMoL-supported monitoring calls on 177 patients from 30 primary care practices (median calls per patient: 10 [interquartile range, 9-10]). Qualitative analyses revealed that most practice teams and patients rated the JAMoL as a practicable and treatment-relevant tool. CONCLUSIONS: The JAMoL enables primary care practice teams to continuously monitor anxiety symptoms and treatment adherence in patients with panic disorder with or without agoraphobia. Within the behavior therapy-oriented treatment program 'Jena-PARADISE', the JAMoL constitutes an important case management tool.

Fall Prevention in a Primary Care Setting.

BACKGROUND: Falls and fall-related injuries are common in community-dwelling elderly people. Effective multifactorial fall prevention programs in the primary care setting may be a promising approach to reduce the incidence rate of falls. METHODS: In a cluster randomized trial in 33 general practices 378 people living independently and at high risk of falling (65 to 94 years old; 285 women) were allocated to either a 16 week exercise-based fall prevention program including muscle strengthening and challenging balance training exercises, combined with a 12 week home-based exercise program (222 participants), or to usual care (156 participants). The main outcome was number of falls over a period of 12 months. Secondary outcomes were the number of fall-related injuries, physical function (Timed-Up-and-Go-Test, TUG, Chair-Stand-Test, CST, modified Romberg Test), and fear of falling. RESULTS: In the intervention group (n=222 patients in 17 general practices) 291 falls occurred, compared to 367 falls in the usual care group (n=156 patients in 16 general practices). We observed a lower incidence rate for falls in the intervention group (incidence rate ratio/IRR: 0.54; 95% confidence interval (CI): [0.35; 0.84], p=0.007) and for fall-related injuries (IRR: 0.66; [0.42; 0.94], p=0.033). Additionally, patients in the intervention group showed significant improvements in secondary endpoints (TUG: -2.39 s, [-3.91; -0.87], p=0.014; mRomberg: 1.70 s, [0.35; 3.04], p=0.037; fear of falling: -2.28 points, [-3.87; -0.69], p=0.022) compared to usual care. CONCLUSION: A complex falls prevention program in a primary care setting was effective in reducing falls and fall-related injuries in community dwelling older adults at risk.

Evaluating Guidelines: A Review of Key Quality Criteria.

BACKGROUND: Guidelines of high methodological quality make an essential contribution to the quality assurance of medical knowledge. The detailed evaluation of guideline quality is a complex and time-consuming task. The answers to a few key questions generally suffice for an initial, rapid assessment of the quality and utility of a guideline. METHOD: We selectively searched the pertinent literature for guideline-assessing instruments and analyzed selected ones with respect to their target group, purpose, orientation, and comprehensiveness. We identified key questions from brief instruments that can be used to assess guideline quality rapidly. RESULTS: A comparison of ten instruments revealed that most were designed to provide a highly detailed assessment of guideline quality. Four recently developed instruments enable a rough and rapid assessment. They focus, in essence, on four key questions: Was the evidence analyzed systematically? Does the evidence support the recommendations? Is the goal of the guideline formulated, and are the authors named? Is the organization of the guideline easy to follow, and are the recommendations clearly signposted? CONCLUSION: Alongside the comprehensive instruments for assessing guidelines, such as DELBI and AGREE II, rapid-assessment instruments are a convenient tool for gaining a quick impression of the value of a guideline.

Endocavitary contrast-enhanced ultrasound: a technique whose time has come?

Endocavitary use of contrast agents in sonography (US) is a relatively new method in diagnostic imaging, competing against gray-scale US, fluoroscopy, and endoscopy. This article describes established indications, demonstrates the techniques of evolving applications, and discusses their potential benefits. These benefits include the ability to obtain precise information about the placement of drains and the extent of fluid collections, and to accurately identify the location and features of strictures in various organs, and those of complications of fluid collections or abscesses, without resorting to ionizing radiation.

Hands-on - general medicine - circuit-training in the auditorium--a practical equivalent to a lecture.

INTRODUCTION: Traditional university teaching formats are of limited use when it comes to conveying the inner workings and specific remit of general medicine in a practical way. Small supervised groups present themselves as a plausible and effective alternative for learning to interact with patients in low prevalence areas. DESCRIPTION OF THE PROJECT: A frontal lecture was transformed into an interactive seminar-like lecture for 280 students. Short kick-off presentations served as an introduction to rotating circuit stations. Knowledge, skills and professional attitude specific to general and family medicine were intensively trained by 28 small groups in and around the auditorium by means of activating didactic methods. The small groups were supervised by experienced GP's trained as tutors. During six days, consisting of 3.5 hour sessions per day, working methods, a large variety of common medical conditions, preventive primary care and care for the elderly were amongst the topics addressed. RESULTS: This new format was successfully implemented and developed with regards to content as well as organisation. Well over 90% of the 274 participating students evaluated tutors' commitment, coherent delivery of content, learner-oriented atmosphere and practical focus positively. Given the advantages of a small-group learning situation, the somewhat cramped conditions were accepted by 92%. DISCUSSION: The innovative concept was able to work successfully within the specific framework of patient care in a general and family medicine setting. A creative approach to the lack of space managed to mobilise resources for practical small-group work. Being able to work on specific general practice problems in a small-group setting and immediately reflect upon them was rated positively overall. CONCLUSIONS: Responsibilities and specific working methods in general practice / family medicine can be trained successfully even with large groups of students when limited space is used creatively. In a supervised circuit-training setting, students are able to apply their existing knowledge and skills in a practical way. Further research is needed to assess individual learning success and gains in competence under this novel learning situation.

Evaluation of a practice team-supported exposure training for patients with panic disorder with or without agoraphobia in primary care - study protocol of a cluster randomised controlled superiority trial.

BACKGROUND: Panic disorder and agoraphobia are debilitating and frequently comorbid anxiety disorders. A large number of patients with these conditions are treated by general practitioners in primary care. Cognitive behavioural exposure exercises have been shown to be effective in reducing anxiety symptoms. Practice team-based case management can improve clinical outcomes for patients with chronic diseases in primary care. The present study compares a practice team-supported, self-managed exposure programme for patients with panic disorder with or without agoraphobia in small general practices to usual care in terms of clinical efficacy and cost-effectiveness. METHODS/DESIGN: This is a cluster randomised controlled superiority trial with a two-arm parallel group design. General practices represent the units of randomisation. General practitioners recruit adult patients with panic disorder with or without agoraphobia according to the International Classification of Diseases, version 10 (ICD-10). In the intervention group, patients receive cognitive behaviour therapy-oriented psychoeducation and instructions to self-managed exposure exercises in four manual-based appointments with the general practitioner. A trained health care assistant from the practice team delivers case management and is continuously monitoring symptoms and treatment progress in ten protocol-based telephone contacts with patients. In the control group, patients receive usual care from general practitioners. Outcomes are measured at baseline (T0), at follow-up after six months (T1), and at follow-up after twelve months (T2). The primary outcome is clinical severity of anxiety of patients as measured by the Beck Anxiety Inventory (BAI). To detect a standardised effect size of 0.35 at T1, 222 patients from 37 general practices are included in each group. Secondary outcomes include anxiety-related clinical parameters and health-economic costs. TRIAL REGISTRATION: Current Controlled Trials [http://ISCRTN64669297].

Can near-peer medical students effectively teach a new curriculum in physical examination?

BACKGROUND: Students in German medical schools frequently complain that the subject 'clinical examination' is not taught in a satisfying manner due to time constraints and lack of personnel resources. While the effectiveness and efficiency of practice-oriented teaching in small groups using near-peer teaching has been shown, it is rarely used in German medical schools. We investigated whether adding a new near-peer teaching course developed with student input plus patient examination under supervision in small groups improves basic clinical examination skills in third year medical students compared to a traditional clinical examination course alone. METHODS: Third year medical students registered for the mandatory curricular clinical examination course at the medical faculty of the Technische Universität München were invited to participate in a randomised trial with blinded outcome assessment. Students were randomised to the control group participating in the established curricular physical examination course or to the intervention group, which received additional near-peer teaching for the same content. The learning success was verified by a voluntary objective structured clinical examination (OSCE). RESULTS: A total of 84 students were randomised and 53 (63%) participated in the final OSCE. Students in the control group scored a median of 57% (25th percentile 47%, 75th percentile 61%) of the maximum possible total points of the OSCE compared to 77% (73%, 80%; p < 0.001) for students in the intervention group. Only two students in the intervention group received a lower score than the best student in the control group. CONCLUSION: Adding a near-peer teaching course to the routine course significantly improved the clinical examination skills of medical students in an efficient manner in the context of a resource-constrained setting.

Use of placebos and nonspecific and complementary treatments by German physicians--rationale and development of a questionnaire for a nationwide survey.

BACKGROUND: We are performing a nationwide survey in a random sample of German general practitioners (GPs), orthopedists, and internists on the use of placebos and nonspecific as well as complementary treatments and their association with basic professional attitudes. In this article we explain the theoretical considerations behind the study approach and the development of the questionnaire. METHODS: Based on a systematic review of published surveys, own surveys on the topic, and on theoretical considerations we developed a preliminary version of a 4-page questionnaire that was tested for feasibility in a convenience sample of 80 participants of a general medical education event. We also performed cognitive interviews with 8 physicians to investigate whether the questions were understood adequately. RESULTS: The questions on typical placebos and complementary treatments were well understood and easy to answer for participants. Discussions about the phrasing of questions on nonspecific treatments during interview reflected the vagueness of this concept; but this did not seem to create major problems when answering the related questions. The original questions regarding basic professional attitudes partly were not understood in the manner intended. The relevant questions were modified but the interviews suggest that these issues are difficult to grasp in a quantitative survey. CONCLUSION: Our testing procedures suggest that our questionnaire is well-suited to investigate our questions with some limitations regarding the issue of basic professional attitudes.

Effects of a complex intervention on fall risk in the general practitioner setting: a cluster randomized controlled trial.

PURPOSE: To study the feasibility of first, reaching functionally declined, but still independent older persons at risk of falls through their general practitioner (GP) and second, to reduce their physiological and psychological fall risk factors with a complex exercise intervention. We investigated the effects of a 16-week exercise intervention on physiological (function, strength, and balance) and psychological (fear of falling) outcomes in community-dwelling older persons in comparison with usual care. In addition, we obtained data on adherence of the participants to the exercise program. METHODS: Tests on physical and psychological fall risk were conducted at study inclusion, and after the 16-week intervention period in the GP office setting. The 16-week intervention included progressive and challenging balance, gait, and strength exercise as well as changes to behavioral aspects. To account for the hierarchical structure in the chosen study design, with patients nested in GPs and measurements nested in patients, a three-level linear mixed effects model was determined for analysis. RESULTS: In total, 33 GPs recruited 378 participants (75.4% females). The mean age of the participants was 78.1 years (standard deviation 5.9 years). Patients in the intervention group showed an improvement in the Timed-Up-and-Go-test (TUG) that was 1.5 seconds greater than that showed by the control group, equivalent to a small to moderate effect. For balance, a relative improvement of 0.8 seconds was accomplished, and anxiety about falls was reduced by 3.7 points in the Falls Efficacy Scale-International (FES-I), in the intervention group relative to control group. In total, 76.6% (N = 170) of the intervention group participated in more than 75% the supervised group sessions. CONCLUSION: The strategy to address older persons at high risk of falling in the GP setting with a complex exercise intervention was successful. In functionally declined, community-dwelling, older persons a complex intervention for reducing fall risks was effective compared with usual care.