Position paper on postgraduate medical education on the occasion of hospital reform - postgraduate medical education must be considered. A joint position paper by Bündnis Junge Ärztinnen und Ärzte and AG Junge Gastroenterologie of the DGVS as well as the Young DGN.

The Bündnis Junger Ärztinnen und Ärzte (BJÄ, Alliance of Young Physicians in Germany) has presented a position paper (PP) on Postgraduate Medical Education (PGME) against the background of an unfolding hospital reform in Germany, and they describe existing deficits of PGME in Germany. Based on this, demands were made of legislators, employers and medical associations which could result in a sweeping reformation of PGME. Hospital reforms can only be accomplished with well trained and motivated physicians. In this respect the BJÄ regards the reform of hospitals and the health-care system as a chance for a reform of PGME, which is long overdue. Legislative competence for PGME lies with the States of the Federal Republic of Germany and this warrants an adjustment of state medical association laws to accommodate the demands of the BJÄ. Generally PGME must be taken into consideration in all health-care legislation, in analogy to the meanwhile globally adopted principle of "Health in all Politics (HiAP)". The BJÄ has made every endeavour to produce this PP. The responsible stakeholders and actors in the health-care system would be well-advised to take the position paper seriously with a dwindling physician work force in hospitals and serious quality deficits in PGME. Hence, the BJÄ must be comprehensively supported. They need congenial partners to define the scientific foundation of all their demands, to test their application under real life conditions in hospital and outpatient care, to pursue research on the impact on patient care and on the intended transformation of the health-care system. This might best be accomplished by partnering with a scientific Association for Postgraduate Medical Education as has been the case in many countries for decades.

Will the Meikirch Model, a New Framework for Health, Induce a Paradigm Shift in Healthcare?

Over the past decades, scientific medicine has realized tremendous advances. Yet, it is felt that the quality, costs, and equity of medicine and public health have not improved correspondingly and, both inside and outside the USA, may even have changed for the worse. An initiative for improving this situation is value-based healthcare, in which value is defined as health outcomes relative to the cost of achieving them. Value-based healthcare was advocated in order to stimulate competition among healthcare providers and thereby reduce costs. The approach may be well grounded economically, but in the care of patients, "value" has ethical and philosophical connotations. The restriction of value to an economic meaning ignores the importance of health and, thus, leads to misunderstandings. We postulate that a new understanding of the nature of health is necessary. We present the Meikirch model, a conceptual framework for health and disease that views health as a complex adaptive system. We describe this model and analyze some important consequences of its application to healthcare. The resources each person needs to meet the demands of life are both biological and personal, and both function together. While scientific advances in healthcare are hailed, these advances focus mainly on the biologically given potential (BGP) and tend to neglect the personally acquired potential (PAP) of an individual person. Personal growth to improve the PAP strongly contributes to meeting the demands of life. Therefore, in individual and public health care, personal growth deserves as much attention as the BGP. The conceptual framework of the Meikirch model supports a unified understanding of healthcare and serves to develop common goals, thereby rendering interprofessional and intersectoral cooperation more successful. The Meikirch model can be used as an effective tool to stimulate health literacy and improve health-supporting behavior. If individuals and groups of people involved in healthcare interact based on the model, mutual understanding of and adherence to treatments and preventive measures will improve. In healthcare, the Meikirch model also makes it plain that neither pay-for-performance nor value-based payment is an adequate response to improve person-centered healthcare. The Meikirch model is not only a unifying theoretical framework for health and disease but also a scaffold for the practice of medicine and public health. It is fully in line with the theory and practice of evidence-based medicine, person-centered healthcare, and integrative medicine. The model offers opportunities to self-motivate people to improve their health-supporting behavior, thereby making preventive approaches and overall healthcare more effective. We believe that the Meikirch model could induce a paradigm shift in healthcare. The healthcare community is hereby invited to acquaint themselves with this model and to consider its potential ramifications.

Understanding the nature of health: New perspectives for medicine and public health. Improved wellbeing at lower costs.

BACKGROUND: Current dilemmas of health care systems call for a new look at the nature of health. This is offered by the Meikirch model. We explore its hypothetical benefit for the future of medicine and public health. Meikirch model: It states: "Health is a dynamic state of wellbeing emergent from conducive interactions between individuals' potentials, life's demands, and social and environmental determinants." "Throughout the life course health results when an individuals' biologically given potential (BGP) and his or her personally acquired potential (PAP), interacting with social and environmental determinants, satisfactorily respond to the demands of life." METHODS: We explored the Meikirch model's possible applications for personal and public health care. RESULTS: The PAP of each individual is the most modifiable component of the model. It responds to constructive social interactions and to personal growth. If an individual's PAP is nurtured to develop further, it likely will contribute much more to health than without fostering. It may also compensate for losses of the BGP. An ensuing new culture of health may markedly improve health in the society. The rising costs of health care presumably are due in part to the tragedy of the commons and to moral hazard. Health as a complex adaptive system offers new possibilities for patient care, particularly for general practitioners. DISCUSSION: Analysis of health systems by the Meikirch model reveals that in many areas more can be done to improve people's health and to reduce health care costs than is done today. The Meikirch model appears promising for individual and public health in low and high income countries. Emphasizing health instead of disease the Meikirch model reinforces article 12 of the International Covenant on Economic, Social and Cultural Rights of the United Nations - that abandons the WHO definition - and thereby may contribute to its reinterpretation.

Challenges for medical educators: results of a survey among members of the German Association for Medical Education.

BACKGROUND: Despite the increasing interest in medical education in the German-speaking countries, there is currently no information available on the challenges which medical educators face. To address this problem, we carried out a web-based survey among the members of the Association for Medical Education (Gesellschaft für medizinische Ausbildung, GMA). METHODS: A comprehensive survey was carried out on the need for further qualifications, expertise and the general conditions of medical educators in Germany. As part of this study, the educators were asked to list the three main challenges which they faced and which required urgent improvement. The results were analysed by means of qualitative content analysis. RESULTS: The questionnaire was completed by 147 of the 373 members on the GMA mailing list (response rate: 39%). The educators named a total of 346 challenges and emphasised the following areas: limited academic recognition for engagement in teaching (53.5% of educators), insufficient institutional (31.5%) and financial support (28.4%), a curriculum in need of reform (22.8%), insufficient time for teaching assignments (18,9%), inadequate teacher competence in teaching methods (18.1%), restricted faculty development programmes (18.1%), limited networking within the institution (11.0%), lack of teaching staff (10.2%), varying preconditions of students (8.7%), insufficient recognition and promotion of medical educational research (5.5%), extensive assessment requirements (4.7%), and the lack of role models within medical education (3.2%). CONCLUSION: The medical educators found the biggest challenges which they faced to be limited academic recognition and insufficient institutional and financial support. Consequently, improvements should be implemented to address these issues.

Strategies for training in diagnostic upper endoscopy: a prospective, randomized trial.

BACKGROUND: Training simulators have been used for decades with success; however, a standardized educational strategy for diagnostic EGD is still lacking. OBJECTIVE: Development of a training strategy for diagnostic upper endoscopy. STUDY DESIGN: Prospective, randomized trial. SETTINGS: A total of 28 medical and surgical residents without endoscopic experience were enrolled. Basic skills evaluations were performed following a structured program involving theoretical lectures and a hands-on course in diagnostic EGD. Subsequently, stratified randomization to clinical plus simulator training (group 1, n = 10), clinical training only (group 2, n = 9), or simulator training only (group 3, n = 9) was performed. Ten sessions of simulator training were conducted for groups 1 and 3 during the 4-month program. Group 2 underwent standard training in endoscopy without supplemental simulator training. The final evaluation was performed on the simulator and by observation of 3 clinical cases. Skills and procedural times were recorded by blinded and unblinded evaluators. MAIN OUTCOME MEASUREMENTS: Time to reach the duodenum, pylorus, or esophagus. RESULTS: All trainees demonstrated a significant reduction in procedure time during a simple manual skills test (P < .05) and significantly better skills scores (P = .006, P = .042 and P = .017) in the simulator independent of the training strategy. Group 1 showed shorter times to intubate the esophagus (61 ± 26 seconds vs 85 ± 30 seconds and 95 ± 36 seconds) and the pylorus (183 ± 65 seconds vs 207 ± 61 seconds and 247 ± 66 seconds) during the clinical evaluation. Blinded assessment of EGD skills showed significantly better results for group 1 compared with group 3. Blinded and unblinded evaluations were not statistically different. LIMITATIONS: Small sample size. CONCLUSIONS: Structured simulator training supplementing clinical training in upper endoscopy appears to be superior to clinical training alone. Simulator training alone does not seem to be sufficient to improve endoscopic skills.

Use of complementary and alternative medicine in Germany - a survey of patients with inflammatory bowel disease.

BACKGROUND: Previous studies have suggested an increasing use of complementary and alternative medicine (CAM) in patients with inflammatory bowel disease (IBD). The aim of our study was to evaluate the use of CAM in German patients with IBD. METHODS: A questionnaire was offered to IBD patients participating in patient workshops which were organized by a self-help association, the German Crohn's and Colitis Association. The self-administered questionnaire included demographic and disease-related data as well as items analysing the extent of CAM use and satisfaction with CAM treatment. Seven commonly used CAM methods were predetermined on the questionnaire. RESULTS: 413 questionnaires were completed and included in the analysis (n = 153 male, n = 260 female; n = 246 Crohn's disease, n = 164 ulcerative colitis). 52 % of the patients reported CAM use in the present or past. In detail, homeopathy (55%), probiotics (43%), classical naturopathy (38%), Boswellia serrata extracts (36%) and acupuncture/Traditional Chinese Medicine (TCM) (33%) were the most frequently used CAM methods. Patients using probiotics, acupuncture and Boswellia serrata extracts (incense) reported more positive therapeutic effects than others. Within the statistical analysis no significant predictors for CAM use were found. 77% of the patients felt insufficiently informed about CAM. CONCLUSION: The use of CAM in IBD patients is very common in Germany, although a large proportion of patients felt that information about CAM is not sufficient. However, to provide an evidence-based approach more research in this field is desperately needed. Therefore, physicians should increasingly inform IBD patients about benefits and limitations of CAM treatment.

The histone-deacetylase inhibitor SAHA potentiates proapoptotic effects of 5-fluorouracil and irinotecan in hepatoma cells.

Treatment for advanced stages of hepatocellular carcinoma (HCC) remains unsatisfactory. While 5-fluorouracil (5-FU) and irinotecan are first-line treatment options for other gastrointestinal tumors, their effect on HCCs is low. Histone-deacetylase inhibitors such as suberoylanilide hydroxamic acid (SAHA) have shown antitumoral activity at micromolar concentrations in a variety of human cancers in vitro and in vivo. Here, we investigated the effects of a combination of 5-FU, irinotecan and SAHA on growth inhibition and apoptosis induction in HCC cell lines. HepG2, Hep1B and MH-7777A hepatoma cell lines and human foreskin fibroblasts as non-transformed controls were incubated with 5-FU, irinotecan and SAHA either alone or in combination. While the single agents did not show any effects on growth of the cell lines, the combination of 5-FU and irinotecan (both 10 microM) led to a moderate increase in apoptosis and proliferation inhibition. Adding 1 microM SAHA increased the apoptosis rate in hepatoma cell lines up to 92% after 72 h, while fibroblasts showed no response (5.5% apoptosis). Induction of apoptosis was paralleled by loss of the mitochondrial transmembrane potential, downregulation of bcl-2 expression and activation of caspase 3 but not caspase 8. In summary, SAHA sensitized HCC cell lines for treatment with an otherwise ineffective combination of 5-FU and irinotecan and led to mitochondrial apoptosis induction. The use of the triple combination could optimize treatment results in vivo and needs further evaluation.

Training with the compactEASIE biologic endoscopy simulator significantly improves hemostatic technical skill of gastroenterology fellows: a randomized controlled comparison with clinical endoscopy training alone.

BACKGROUND: The Erlangen Active Simulator for Interventional Endoscopy (EASIE) was introduced in 1997 for interventional endoscopy training. compactEASIE developed in 1998 is a modified, light-weight version of the original model. Objective evidence of the benefits of training with these models is limited. A randomized controlled study, therefore, was conducted to compare the effects of intensive 7-month, hands-on training in hemostatic techniques by using the compactEASIE model (in addition to clinical endoscopic training) vs. pure clinical training in endoscopic hemostatic methods. METHODS: Thirty-seven fellows in gastroenterology in New York City area training programs were enrolled. Baseline skills were assessed on the simulator for the following techniques: manual skills, injection and electrocoagulation, hemoclip application, and variceal ligation. Twenty-eight fellows were then randomized into two comparable groups. Those randomized to Group A received purely clinical training in endoscopic hemostatic techniques at their hospitals. Those in Group B, in addition, were trained by experienced tutors in 3 full-day hemostasis workshops over 7 months. Both groups underwent a final evaluation on the compactEASIE simulator conducted by their tutors and additional evaluators who were blinded to the method of training. Initial and final evaluation scores were compared for each group and between groups. Outcomes of actual clinical hemostatic procedures performed during the study period also were analyzed. RESULTS: Ten of 14 fellows randomized to Group A (standard training) and 13 of 14 in Group B (intensive training) returned for the final evaluation. For Group B, scores for all techniques were significantly improved. In Group A, a significant improvement was noted for variceal ligation alone. CONCLUSIONS: compactEASIE simulator training (3 sessions over 7 months), together with clinical endoscopic training resulted in objective improvement in the performance by fellows of all 4 endoscopic hemostatic techniques, whereas significant improvement was noted for variceal ligation alone for fellows who had standard clinical training. In clinical practice, fellows who had intensive simulator/clinical training had a significantly higher success rate and a nonsignificant reduction in the frequency of occurrence of complications.