[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.

[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.

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.

The influence of age, gender and socio-economic status on multimorbidity patterns in primary care. First results from the multicare cohort study.

BACKGROUND: Multimorbidity is a phenomenon with high burden and high prevalence in the elderly. Our previous research has shown that multimorbidity can be divided into the multimorbidity patterns of 1) anxiety, depression, somatoform disorders (ADS) and pain, and 2) cardiovascular and metabolic disorders. However, it is not yet known, how these patterns are influenced by patient characteristics. The objective of this paper is to analyze the association of socio-demographic variables, and especially socio-economic status with multimorbidity in general and with each multimorbidity pattern. METHODS: The MultiCare Cohort Study is a multicentre, prospective, observational cohort study of 3.189 multimorbid patients aged 65+ randomly selected from 158 GP practices. Data were collected in GP interviews and comprehensive patient interviews. Missing values have been imputed by hot deck imputation based on Gower distance in morbidity and other variables. The association of patient characteristics with the number of chronic conditions is analysed by multilevel mixed-effects linear regression analyses. RESULTS: Multimorbidity in general is associated with age (+0.07 chronic conditions per year), gender (-0.27 conditions for female), education (-0.26 conditions for medium and -0.29 conditions for high level vs. low level) and income (-0.27 conditions per logarithmic unit). The pattern of cardiovascular and metabolic disorders shows comparable associations with a higher coefficient for gender (-1.29 conditions for female), while multimorbidity within the pattern of ADS and pain correlates with gender (+0.79 conditions for female), but not with age or socioeconomic status. CONCLUSIONS: Our study confirms that the morbidity load of multimorbid patients is associated with age, gender and the socioeconomic status of the patients, but there were no effects of living arrangements and marital status. We could also show that the influence of patient characteristics is dependent on the multimorbidity pattern concerned, i.e. there seem to be at least two types of elderly multimorbid patients. First, there are patients with mainly cardiovascular and metabolic disorders, who are more often male, have an older age and a lower socio-economic status. Second, there are patients mainly with ADS and pain-related morbidity, who are more often female and equally distributed across age and socio-economic groups. TRIAL REGISTRATION: ISRCTN89818205.

An interdisciplinary intervention to prevent falls in community-dwelling elderly persons: protocol of a cluster-randomized trial [PreFalls].

BACKGROUND: Prevention of falls in the elderly is a public health target in many countries around the world. While a large number of trials have investigated the effectiveness of fall prevention programs, few focussed on interventions embedded in the general practice setting and its related network. In the Prevent Falls (PreFalls) trial we aim to investigate the effectiveness of a pre-tested multi-modal intervention compared to usual care in this setting. METHODS/DESIGN: PreFalls is a controlled multicenter prospective study with cluster-randomized allocation of about 40 general practices to an experimental or a control group. We aim to include 382 community dwelling persons aged 65 and older with an increased risk of falling. All participating general practitioners are trained to systematically assess the risk of falls using a set of validated tests. Patients from intervention practices are invited to participate in a 16-weeks exercise program with focus on fall prevention delivered by specifically trained local physiotherapists. Patients from practices allocated to the control group receive usual care. Main outcome measure is the number of falls per individual in the first 12 months (analysis by negative binomial regression). Secondary outcomes include falls in the second year, the proportion of participants falling in the first and the second year, falls associated with injury, risk of falls, fear of falling, physical activity and quality of life. DISCUSSION: Reducing falls in the elderly remains a major challenge. We believe that with its strong focus on a both systematic and realistic fall prevention strategy adapted to primary care setting PreFalls will be a valuable addition to the scientific literature in the field. TRIAL REGISTRATION: NCT01032252.

[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.

[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.

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.

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.

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.

Most like it but some don't--attitudes of vocational trainees in general practice towards evidence-based medicine.

RATIONALE AND OBJECTIVES: Vocational trainees in general practice are often confronted with new and unusual situations. The application of the principles and techniques of evidence-based medicine (EBM) could often be appropriate in these situations. We aimed to investigate attitudes towards EBM among doctors undergoing postgraduate training in general practice in Germany. In particular, we were interested in which aspects the answers of doctors with an overall negative attitude towards EBM differed from those with a positive attitude. METHODS: A total of 153 doctors participating in courses for postgraduate medical training in general practice were asked to fill in a questionnaire on attitudes towards EBM and relevance of clinical research. Answers of doctors with a negative attitude towards EBM (negative sum in the questions asking personal judgment on EBM) were compared with those of the remaining doctors. RESULTS: A total of 142 (93%) doctors returned the questionnaire and 121 responded to the questions on EBM (21 responded that they had not heard about EBM). On average, attitudes towards EBM were positive; however, nine doctors gave negative ratings. EBM-sceptics were similar regarding age, years working as doctors and working hours per week, but were more often male (P = 0.03). EBM-sceptics considered keeping up to date as important as non-sceptics but were significantly (P < 0.001) more negative regarding whether EBM is an important decision aid in one's personal work, whether it helps to identify the best clinical options and whether it constrains therapeutic freedom. CONCLUSION: Overall, doctors specializing in general practice in Germany have a quite positive attitude towards EBM. A small minority, however, seems to consider EBM a threat to their professional autonomy.