Objective structured clinical examination to teach competency in planetary health care and management - a prospective observational study.

BACKGROUND: Health professionals are increasingly called upon and willing to engage in planetary health care and management. However, so far, this topic is rarely covered in medical curricula. As the need for professional communication is particularly high in this subject area, this study aimed to evaluate whether the objective structured clinical examination (OSCE) could be used as an accompanying teaching tool. METHODS: During the winter semester 2022/2023, 20 third- and fifth-year medical students voluntarily participated in a self-directed online course, three workshops, and a formal eight-station OSCE on planetary health care and management. Each examinee was also charged alternatingly as a shadower with the role of providing feedback. Experienced examiners rated students' performance using a scoring system supported by tablet computers. Examiners and shadowers provided timely feedback on candidates` performance in the OSCE. Immediately after the OSCE, students were asked about their experience using a nine-point Likert-scale survey and a videotaped group interview. Quantitative analysis included the presentation of the proportional distribution of student responses to the survey and of box plots showing percentages of maximum scores for the OSCE performance. The student group interview was analyzed qualitatively. RESULTS: Depending on the sub-theme, 60% -100% of students rated the subject of planetary health as likely to be useful in their professional lives. Similar proportions (57%-100%) were in favour of integrating planetary health into required courses. Students perceived learning success from OSCE experience and feedback as higher compared to that from online courses and workshops. Even shadowers learned from observation and feedback discussions. Examiners assessed students' OSCE performance at a median of 80% (interquartile range: 83%-77%) of the maximum score. CONCLUSIONS: OSCE can be used as an accompanying teaching tool for advanced students on the topic of planetary health care and management. It supports learning outcomes, particularly in terms of communication skills to sensitise and empower dialogue partners, and to initiate adaptation steps at the level of individual patients and local communities.

[Examining in General Practice: Licensure Examinations in a General Practice Setting]. / Prüfen in der Allgemeinmedizin ­ Staatsexamina im ambulanten hausärztlichen Setting.

General practitioners play a major role in the health care of the population. Only a small proportion of patients receives care from specialised consultants, in a hospital or in a university hospital. Most of the patients consult a general practitioner. The strengthening of general practice that is called for in the Master Plan for Medical Studies 2020 in new state examination formats, for instance, means that this central position in patient care will be reflected in studies and examinations in the future. The general medical setting is subject to a specific background with unselected patients and a hermeneutic understanding of cases. The format of the new final examination promotes general medical and interdisciplinary competencies in medical interviewing, physical examination, dealing with diseases that can be treated on an outpatient basis, prevention, and the application of general medical guidelines of ethics and law. The standardised oral-practical examination has newly been designed by the Institute for Medical and Pharmaceutical Examination Questions (IMPP). It includes real patients in an outpatient setting. In eight steps, it integrates communicative and technical examination aspects. Two trained examiners will observe and assess the performance of graduates using standardised evaluation forms. The new examination format was developed in 2019 by the IMPP and faculty from various medical schools, was tested in five general medical teaching practices, revised, and then piloted in fourteen examinations. Standardised specifications for the examination process, spatial equipment, and examiner training were developed by IMPP. With approximately 10,000 examinees per year and two students per examination day, a total of 5,000 examination days will be required in general practices. The expertise of the German College of General Practicioners and Family Physicians (DEGAM), the Society of University Teachers of General Medicine (GHA), and the university locations, together with the great potential as the largest specialist group in Germany suggest that the goal of recruiting and motivation of practices appears achievable. With regard to funding, political decisions are necessary. In an increasingly complex care system, the redesign of the oral-practical examination in the outpatient setting contributes to strengthening interdisciplinary and multi-professional cooperation.

Communication with patients with limited prognosis-an integrative mixed-methods evaluation study.

PURPOSE: Oncological societies advocate the continuity of care, specialized communication, and early integration of palliative care. To comply with these recommendations, an interprofessional, longitudinally-structured communication concept, the Milestone Communication Approach (MCA), was previously developed, implemented, and evaluated. Our research question is: what are possible explanations from the patient perspective for prognosis and advance care planning being rarely a topic and for finding no differences between MCA and control groups concerning distress, quality of life, and mood? METHODS: A pragmatic epistemological stance guided the study. A mixed-methods design was chosen including a pragmatic randomized trial (n = 171), qualitative interviews with patients (n = 13) and caregivers (n = 12), and a content analysis (133 milestone conversations, 54 follow-up calls). Data analysis involved the pillar integration process. RESULTS: Two pillar themes emerged: 1 "approaching prognosis and advance care planning"; 2 "living with a life-threatening illness". Information on prognosis seemed to be offered, but patients' reactions were diverse. Some patients have to deal with having advanced lung cancer while nonetheless feeling healthy and seem not to be ready for prognostic information. All patients seemed to struggle to preserve their quality of life and keep distress under control. CONCLUSION: Attending to patients' questions, worries and needs early in a disease trajectory seems key to helping patients adjust to living with lung cancer. If necessary clinicians should name their predicament: having to inform about prognosis versus respecting the patients wish to avoid it. Research should support better understanding of patients not wishing for prognostic information to successfully improve communication strategies. TRIAL REGISTRATION: Registration: German Clinical Trial Register No. DRKS00013649, registration date 12/22/2017, ( https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00013649 ) and No. DRKS00013469, registration date 12/22/2017, ( https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00013469 ).

[Heidelberg Milestones Communication (HeiMeKOM) - Experiences, Best Practice Examples and Recommendations from the Final Symposium on January 30 and 31 in 2020]. / Heidelberger Meilenstein Kommunikation (HeiMeKOM) ­ Erfahrungen, Best Practice Beispiele und Empfehlungen aus dem Abschluss-Symposium am 30./31. Januar 2020.

The National Cancer Plan emphasises the importance of medical communication and calls for its integration into medical education and training. In this context, the Milestone Communication Approach meets the communicative challenges in dealing with lung cancer patients. Interprofessional tandems, consisting of doctors and nurses, conduct structured conversations at defined moments with patients and their relatives. The concept aims at shared decision making, continuity in the care of lung cancer patients and the early integration of palliative care. During the symposium on the Heidelberg Milestone Communication in January 2020, recommendations on the care situation of lung cancer patients in advanced stages were developed. In addition, the further adaptability of HeiMeKOM to other settings and hospitals and to other diseases was discussed as well as the possibility of implementing such a concept in standard care. This article presents the experiences, best practice examples and recommendations discussed during the symposium in order to enable their extrapolation to other similarly oriented projects. The long-term goal is to transfer the milestone concept to other hospital, primarily certified lung cancer centers, and to ensure permanent funding. For further dissemination of the concept and, above all, to have it established in standard care, health policy awareness and support are required in addition to the integration of the concept in competence catalogues of continuing medical and nursing education.

Effects of an Interprofessional Communication Approach on Support Needs, Quality of Life, and Mood of Patients with Advanced Lung Cancer: A Randomized Trial.

BACKGROUND: To address the support needs of newly diagnosed patients with lung cancer with limited prognosis, the Milestone Communication Approach (MCA) was developed and implemented. The main elements of the MCA are situation-specific conversations along the disease trajectory conducted by an interprofessional tandem of physician and nurse. The aim of the study was to evaluate the effects of MCA on addressing support needs, quality of life, and mood as compared with standard oncological care. PATIENTS AND METHODS: A randomized trial was conducted with baseline assessment and follow-up assessments at 3, 6, and 9 months in outpatients with newly diagnosed lung cancer stage IV at a German thoracic oncology hospital. The primary outcome was the Health System and Information Needs subscale of the Short Form Supportive Care Needs Survey (SCNS-SF34-G) at 3-month follow-up. Secondary outcomes included the other subscales of the SCNS-SF34-G, the Schedule for the Evaluation of Individual Quality of Life, the Functional Assessment of Cancer Therapy lung module, the Patient Health Questionnaire for Depression and Anxiety, and the Distress Thermometer. RESULTS: At baseline, 174 patients were randomized, of whom 102 patients (MCA: n = 52; standard care: n = 50) provided data at 3-month follow-up. Patients of the MCA group reported lower information needs at 3-month follow-up (mean ± SD, 33.4 ± 27.5; standard care, 43.1 ± 29.9; p = .033). No effects were found for secondary outcomes. CONCLUSION: MCA lowered patient-reported information needs but did not have other effects. MCA contributed to tailored communication because an adequate level of information and orientation set the basis for patient-centered care. IMPLICATIONS FOR PRACTICE: By addressing relevant issues at predefined times, the Milestone Communication Approach provides individual patient-centered care facilitating the timely integration of palliative care for patients with a limited prognosis. The needs of patients with lung cancer must be assessed and addressed throughout the disease trajectory. Although specific topics may be relevant for all patients, such as information about the disease and associated health care, situations of individual patients and their families must be considered. Additionally, using the short form of the Supportive Care Needs Survey in clinical practice to identify patients' problems might support individually targeted communication and preference-sensitive care.

Teaching Conflicts of Interest and Shared Decision-Making to Improve Risk Communication: a Randomized Controlled Trial.

BACKGROUND: Risk communication is a core aspect of a physician's work and a fundamental prerequisite for successful shared decision-making. However, many physicians are not able to adequately communicate risks to patients due to a lack of understanding of statistics as well as inadequate management of conflicts of interest (COI). OBJECTIVE: To evaluate the effects of an integrated curriculum encompassing COI and shared decision-making on the participants' risk communication competence, that is, their competence to advise patients on the benefits and harms of diagnostic or therapeutic interventions. DESIGN: A rater-blind randomized controlled trial with a 30 (± 1)-week follow-up conducted from October 2016 to June 2017 at two German academic medical centers. PARTICIPANTS: Sixty-three medical students in their fourth or fifth year. INTERVENTIONS: Participants received either a newly developed 15-h curriculum or a course manual adapted from teaching as usual. MAIN MEASURES: Primary outcome: change in risk communication performance in a video-observed structured clinical examination (VOSCE). KEY RESULTS: Participants were 25.7 years old on average (SD 3.6); 73% (46/63) were female. Increase in risk communication performance was significantly higher in the intervention group with post-intervention Cohen's d of 2.35 (95% confidence interval (CI) 1.62 to 3.01, p < 0.01) and of 1.83 (CI 1.13 to 2.47, p < 0.01) 30 (± 1) weeks later. Secondary outcomes with the exception of frequency of interactions with the pharmaceutical industry also showed relevant improvements in the intervention as compared with the control group (d between 0.91 and 2.04 (p < 0.001)). CONCLUSIONS: Our results show that an integrated curriculum encompassing COI and risk communication leads to a large and sustainable increase in risk communication performance. We interpret the large effect sizes to be a result of the integration of topics that are usually taught separately, leading to a more effective organization of knowledge. TRIAL REGISTRATION: The trial is registered in the International Clinical Trials Registry with the trial number DRKS00010890.

Implementation of the milestones communication approach for patients with limited prognosis: evaluation of intervention fidelity.

BACKGROUND: Despite improvements in diagnostics and therapy, the majority of lung tumours are diagnosed at advanced stage IV with a poor prognosis. Due to the nature of an incurable disease, patients need to engage in shared decision making on advance care planning. To implement this in clinical practice, effective communication between patients, caregivers and healthcare professionals is essential. The Heidelberg Milestones Communication Approach (MCA) is delivered by a specifically trained interprofessional tandem and consists of four milestone conversations (MCs) at pivotal times in the disease trajectory. MC 1 (Diagnosis): i.e. prognosis; MC 2 (Stable disease): i.e. prognostic awareness; MC 3 (Progression): i.e. reassessment; MC 4 (Best supportive care): i.e. end of treatment. In between MCs, follow-up calls are carried out to sustain communication. This study aimed to assess to what extent the MCA was implemented as planned and consolidated in specialized oncology practice. METHODS: A prospective observational process evaluation study was conducted, which focused on the implementation fidelity of the MCA. All MCs during two assessment periods were included. We analysed all written records of the conversations, which are part of the routine documentation during MCs and follow-up calls. Adherence to key aspects of the manual was documented on structured checklists at the beginning of the implementation of the MCA and after 6 months. The analysis was descriptive. Differences between the two assessment periods are analysed with chi-square tests. RESULTS: A total of 133 MCs and 54 follow-up-calls (t1) and of 172 MCs and 92 follow-up calls (t2) were analysed. MC 2 were the most frequently completed conversations (n = 51 and n = 47). Advance care planning was discussed in 26 and 13% of MC 2 in the respective assessment periods; in 31 and 47% of MC 2, prognostic awareness was recorded. The most frequently documented topic in the follow-up calls was the physical condition in patients (82 and 83%). CONCLUSION: The implementation of a trajectory-specific communication concept was largely successful. Additional studies are needed to understand how fidelity could be further improved. TRIAL REGISTRATION: DRKS00013469 / Date of registration: 22.12.2017.

Length Polymorphisms in the Angiotensin I-Converting Enzyme Gene and the Serotonin-Transporter-Linked Polymorphic Region Constitute a Risk Haplotype for Depression in Patients with Coronary Artery Disease.

Genetic variations affecting the course of depressive symptoms in patients with coronary artery disease (CAD) have not yet been well studied. Therefore, we set out to investigate whether distinct haplotypes of the two insertion/deletion polymorphisms in the serotonin-transporter-linked polymorphic region (5-HTTLPR) and the angiotensin I-converting enzyme (ACE) gene located on chromosome 17 can be identified as risk factors for trajectories of depression. Clinical and genotyping data were derived from 507 depressed CAD patients participating in the randomized, controlled, multicenter Stepwise Psychotherapy Intervention for Reducing Risk in Coronary Artery Disease (SPIRR-CAD) trial, of whom the majority had an acute cardiac event before study inclusion. Depression scores on the Hospital Anxiety and Depression Scale (HADS) were assessed at baseline and at five follow-up time points up to 2 years after study entrance. At baseline, depression scores did not significantly differ between patients carrying the risk haplotype ACE D/D, 5-HTTLPR I/I (n = 46) and the non-risk haplotypes (n = 461, 10.9 ± 2.7 versus 10.4 ± 2.5, p = 0.254). HADS-depression scores declined from study inclusion during the first year irrespective of the genotype. At each follow-up time point, HADS-depression scores were significantly higher in ACE D/D, 5-HTTLPR I/I carriers than in their counterparts. Two years after study inclusion, the mean HADS depression score remained 1.8 points higher in patients with the risk haplotype as compared to subjects not carrying this haplotype (9.9 ± 4.2 versus 8.1 ± 4.0, p = 0.009). In summary, the presence of the ACE D/D, 5-HTTLPR I/I haplotype may be a vulnerability factor for comorbid depressive symptoms in CAD patients.

[Implementing choosing wisley in undergraduate medical education]. / "Klug entscheiden" in der Gastroenterologie ­ eine Wissenschaftskompetenz, die bereits im Medizinstudium gelernt werden muss.

The principles of evidence-based medicine and the "choosing wisley" initiatives create a foundation for patient-centred medicine, which can prevent an overuse or undertreatment for patients. In order to achieve nationwide implementation in Germany, it makes sense to anchor the necessary skills, in particular scientific skills, more firmly in medical studies and to test them in the state exams. With the "Masterplan Medizinstudium 2020", undergraduate medical education should focus more on the teaching and learning of skills and abilities, instead of on the strong tradition of imparting facts and knowledge. Innovative examination formats which are based on the "choosing wisley" recommendations of the DGVS, such as key feature cases and OSCE examinations, as well as examinations on patients in the future, are integral to the M4 state examination included in the current draft of Medical Licensing Regulations (ÄApprO) and will help with the nationwide implementation of these recommendations.

Correction to: Exam performance of different admission quotas in the first part of the state examination in medicine: a cross-sectional study.

An amendment to this paper has been published and can be accessed via the original article.

Exam performance of different admission quotas in the first part of the state examination in medicine: a cross-sectional study.

BACKGROUND: Most medical students in Germany are admitted via selection procedures, which are adjusted to the demands of the universities. At Lübeck medical school, scores from interviews that measure non-academic skills and pre-university GPAs are summed to arrive at an admission decision. This article seeks to illuminate the effectiveness of this selection procedure in comparison to other non-selected student groups. METHODS: Quota information and exam results from the first federal exam were linked for students admitted to Lübeck medical school between 2012 and 2015 (N = 655). Five different student groups (university-specific selection quota, pre-university GPA quota, waiting time quota, ex-ante quota and foreign students) were compared regarding exam attempts, written and oral grades, temporal continuity and examination success in the standard study period. RESULTS: While the pre-university GPA quota outperformed all other quotas regarding written and oral grades, it did not differ from the selection quota regarding exam attempts, temporal continuity and examination success in the standard study period. Students in the waiting time and ex-ante quotas performed inferior by comparison. The results of foreign students were the most problematic. CONCLUSION: Students selected by the university show high temporal continuity and examination success. These results, and possible advantages in physician eligibility, argue for the utilisation of non-academic skills for admission.

Somatic and sociodemographic predictors of depression outcome among depressed patients with coronary artery disease - a secondary analysis of the SPIRR-CAD study.

BACKGROUND: Depressive symptoms are common in patients with coronary artery disease (CAD) and are associated with an unfavourable outcome. Establishing prognostic patient profiles prior to the beginning of mental health care may facilitate higher efficacy of targeted interventions. The aim of the current study was to identify sociodemographic and somatic predictors of depression outcome among depressed patients with CAD. METHODS: Based on the dataset of the multicentre SPIRR-CAD randomised controlled trial (n = 570 patients with CAD and ≥ 8 points on the Hospital Anxiety and Depression Scale (HADS)), 141 potential sociodemographic and somatic predictors of the change in the HADS-D depression score from baseline to 18-month-follow-up were derived in two different ways. We screened for univariable association with response, using either analysis of (co)variance or logistic regression, respectively, both adjusted for baseline HADS-D value and treatment group. To guard against overfitting, multivariable association was evaluated by a linear or binomial (generalised) linear model with lasso regularisation, a machine learning approach. Outcome measures were the change in continuous HADS-D depression scores, as well as three established binary criteria. The Charlson Comorbidity Index (CCI) was calculated to assess possible influences of comorbidities on our results and was also entered in our machine learning approach. RESULTS: Higher age (p = 0.002), unknown previous myocardial infarction (p = 0.013), and a higher heart rate variability during numeracy tests (p = .020) were univariably associated with a favourable depression outcome, whereas hyperuricemia (p ≤ 0.003), higher triglycerides (p = 0.014), NYHA class III (p ≤ 0.028), state after resuscitation (p ≤ 0.042), intake of thyroid hormones (p = 0.007), antidiabetic drugs (p = 0.015), analgesic drugs (p = 0.027), beta blockers (p = 0.035), uric acid drugs (p ≤ 0.039), and anticholinergic drugs (p = 0.045) were associated with an adverse effect on the HADS-D depression score. In all analyses, no significant differences between study arms could be found and physical comorbidities also had no significant influence on our results. CONCLUSION: Our findings may contribute to identification of somatic and sociodemographic predictors of depression outcome in patients with CAD. The unexpected effects of specific medication require further clarification and further research is needed to establish a causal association between depression outcome and our predictors. TRIAL REGISTRATION: www.clinicaltrials.gov NCT00705965 (registered 27th of June, 2008). www.isrctn.com ISRCTN76240576 (registered 27th of March, 2008).

[Competence-based assessment in the national licensing examination in Germany]. / Kompetenzorientiert prüfen im Staatsexamen Medizin.

In Germany, future physicians have to pass a national licensing examination at the end of their medical studies. Passing this examination is the requirement for the license to practice medicine. The Masterplan Medizinstudium 2020 with its 41 measures aims to shift the paradigm in medical education and medical licensing examinations.The main goals of the Masterplan include the development towards competency-based and practical medical education and examination as well as the strengthening of general medicine. The healthcare policy takes into account social developments, which are very important for the medical education and licensing examination.Seven measures of the Masterplan relate to the realignment of the licensing examinations. Their function to drive learning should better support students in achieving the study goal defined in the German Medical Licensure Act: to educate a medical doctor scientifically and practically who is qualified for autonomous and independent professional practice, postgraduate education and continuous training.

A Stepwise Psychotherapy Intervention for Reducing Risk in Coronary Artery Disease (SPIRR-CAD): Results of an Observer-Blinded, Multicenter, Randomized Trial in Depressed Patients With Coronary Artery Disease.

BACKGROUND: Depression predicts adverse prognosis in patients with coronary artery disease (CAD), but previous treatment trials yielded mixed results. We tested the hypothesis that stepwise psychotherapy improves depressive symptoms more than simple information. METHODS: In a multicenter trial, we randomized 570 CAD patients scoring higher than 7 on the Hospital Anxiety and Depression Scale-depression subscale to usual care plus either one information session (UC-IS) or stepwise psychotherapy (UC-PT). UC-PT patients received three individual psychotherapy sessions. Those still depressed were offered group psychotherapy (25 sessions). The primary outcome was changed in the Hospital Anxiety and Depression Scale-depression scores from baseline to 18 months. Preplanned subgroup analyses examined whether treatment responses differed by patients' sex and personality factors (Type D). RESULTS: The mean (standard deviation) depression scores declined from 10.4 (2.5) to 8.7 (4.1) at 18 months in UC-PT and from 10.4 (2.5) to 8.9 (3.9) in UC-IS (both p < .001). There was no significant group difference in change of depressive symptoms (group-by-time effect, p = .90). Preplanned subgroup analyses revealed no differences in treatment effects between men versus women (ptreatment-by-sex interaction = .799) but a significant treatment-by-Type D interaction on change in depressive symptoms (p = .026) with a trend for stronger improvement with UC-PT than UC-IS in Type D patients (n = 341, p = .057) and no such difference in improvement in patients without Type D (n = 227, p = .54). CONCLUSIONS: Stepwise psychotherapy failed to improve depressive symptoms in CAD patients more than UC-IS. The intervention might be beneficial for depressed CAD patients with Type D personality. However, this finding requires further study. TRIAL REGISTRATION: www.clinicaltrials.gov NCT00705965; www.isrctn.com ISRCTN76240576.

[Competence-based catalogue of learning objectives for conducting medical consultations]. / Kompetenzbasierter Lernzielkatalog ¼Ärztliche Gesprächsführung« .

ISSUE: In 2012 the German medical licensure regulations (Approbationsordnung) made teaching and assessing the conduction of medical consultations a mandatory part of medical education. A catalogue of learning objectives (LO) based on existing references was developed to assist medical schools in meeting this requirement. METHODS: A body of relevant material was compiled using literature research and surveying experts. Then, in a multiphase Delphi process, this was evaluated and condensed by an interdisciplinary working group in dialogue with external (clinical) experts. Competence levels and examples of clinical application were assigned to enhance implementation. The catalogue was revised by the medical faculties, professional associations and the BVMD. RESULTS: This learning catalogue comprised 116 learning objectives for the specific skills necessary to conducting medical consultations as well as exemplary application contexts. The catalogue proved to be practical in terms of developing curricula and networking at medical schools. DISCUSSION: This catalogue of learning objectives can serve as the basis for developing a sample communication curriculum for use by medical faculties.

The benefit of repetitive skills training and frequency of expert feedback in the early acquisition of procedural skills.

BACKGROUND: Redundant training and feedback are crucial for successful acquisition of skills in simulation trainings. It is still unclear how or how much feedback should best be delivered to maximize its effect, and how learners' activity and feedback are optimally blended. To determine the influence of high- versus low-frequency expert feedback on the learning curve of students' clinical procedural skill acquisition in a prospective randomized study. METHODS: N = 47 medical students were trained to insert a nasogastric tube in a mannequin, including structured feedback in the initial instruction phase at the beginning of the training (T1), and either additional repetitive feedback after each of their five subsequent repetitions (high-frequency feedback group, HFF group; N = 23) or additional feedback on just one occasion, after the fifth repetition only (low-frequency feedback group, LFF group; N = 24). We assessed a) task-specific clinical skill performance and b) global procedural performance (five items of the Integrated Procedural Performance Instrument (IPPI); on the basis of expert-rated videotapes at the beginning of the training (T1) and during the final, sixth trial (T2). RESULTS: The two study groups did not differ regarding their baseline data. The calculated ANOVA for task-specific clinical skill performance with the between-subject factor 'Group' (HFF vs. LFF) and within-subject factors 'Time' (T1 vs. T2) turned out not to be significant (p < .147). An exploratory post-hoc analyses revealed a trend towards a superior performance of HFF compared to LFF after the training (T2; p < .093), whereas both groups did not differ at the beginning (T1; p < .851). The smoothness of the procedure assessed as global procedural performance, was superior in HFF compared to LFF after the training (T2; p < .004), whereas groups did not differ at the beginning (T1; p < .941). CONCLUSION: Deliberate practice with both high- and low-frequency intermittent feedback results in a strong improvement of students' early procedural skill acquisition. High-frequency intermittent feedback, however, results in even better and smoother performance. We discuss the potential role of the cognitive workload on the results. We advocate a thoughtful allocation of tutor resources to future skills training.

Digital rectal examination skills: first training experiences, the motives and attitudes of standardized patients.

BACKGROUND: Physical clinical examination is a core clinical competence of medical doctors. In this regard, digital rectal examination (DRE) plays a central role in the detection of abnormalities of the anus and rectum. However, studies in undergraduate medical students as well as newly graduated doctors show that they are insufficiently prepared for performing DRE. Training units with Standardized Patients (SP) represent one method to deliver DRE skills. As yet, however, it is little known about SPs' attitudes. METHODS: This is a qualitative study using a grounded theory approach. Interviews were conducted with 4 standardized patients about their experiences before, during and after structured SP training to deliver DRE competencies to medical students. The resulting data were subjected to thematic content analysis. RESULTS: Results show that SPs do not have any predominant motives for DRE program participation. They participate in the SP training sessions with relatively little prejudice and do not anticipate feeling highly vulnerable within teaching sessions with undergraduate medical students. CONCLUSIONS: The current study examined SPs' motives, views, expectations and experiences regarding a DRE program during their first SP training experiences. The results enabled us to derive distinct action guidelines for the recruitment, informing and briefing of SPs who are willing to participate in a DRE program.

[From stand-alone solution to longitudinal communication curriculum--development and implementation at the Faculty of Medicine in Heidelberg]. / Von der Insellösung zum Longitudinalen Kommunikationscurriculum--Entwicklung und Implementierung am Beispiel der Medizinischen Fakultät Heidelberg.

At the Faculty of Medicine in Heidelberg, implementation of an interdisciplinary longitudinal curriculum was started in 2001 with the goal of achieving sustained promotion of communicative and clinical competences. The aim of this paper is to describe the development and implementation of Heidelberg's longitudinal communication curriculum. Furthermore, innovative aspects and strategies are discussed. The methodological approaches for development and implementation were Kern's "Six-step Approach" and a SWOT analysis. The process resulted in an innovative communication curriculum that starts with an integrated curriculum for developing clinical and communicative competence in the pre-clinical phase and continues in the clinical phase with medical communication and interactive training. Satisfaction with the communication curriculum and its effectiveness were rated highly by students. Residents who had graduated from Faculty of Medicine in Heidelberg rated the extent to which they had communicative competencies at the time of their graduation at their disposal significantly higher than residents who had graduated from the other 4 medical faculties in Baden-Württemberg. The experiences gained in Heidelberg can be applied by other faculties.

[Integrated Peer Teaching of Communication and Clinical Skills: How to Train Student Tutors?]. / Integriertes Peer Teaching klinischer und kommunikativer Kompetenzen: Wie bereiten wir studentische Tutoren darauf vor?

AIM: This paper describes the theory-based development of a standardized training model for peer tutors. The aim is to qualify tutors to teach communication skills integrated with practical clinical skills, to medical students in the pre-clinical curriculum. As a result, students are encouraged to form a basic understanding of the biopsychosocial model of diseases early in their studies. METHOD: The training model's design is based on the Kern model for curriculum development as adapted by McLean et al., who outlined the following steps: planning, implementation, and evaluation/feedback. Our focus is on development, review of feasibility, and evaluation as measured by the subjectively perceived effectiveness of the implemented training model. 2 target groups were considered: the peer tutors and the student tutees. RESULTS: In 2009, a 3-step training model consisting of 12 units was developed, based on the theory of patient-centered communication and the biopsychosocial model. The training was rated very positively on a 5-point Likert scale by all tutors at 2 points in time: t1 (directly after training) and t2 (after conducting 2 tutorials) (t1: M=1.67; SD=±0.86; t2: M=1.75; SD=±0.71). On a 6-point Likert scale, the tutees also evaluated their communication and clinical skills as being significantly better after completing the 10 tutorials (t2: scale for interaction and communication: M=4.81; SD: 1.09; scale for clinical examination: M=4.99; SD: 0.85) than before the tutorials (t0: scale for communication and interaction: M=3.18; SD=1.15; scale for clinical examination: M=2.88; SD: 1.09). CONCLUSIONS: By implementing a standardized tutor training model, one can qualify peer tutors to teach communication skills integrated with practical clinical skills during the pre-clinical phase. Practice teaching of the curricular material via role playing, tutorial simulation and an extensive feedback session, along with the definition of clinical standards for recording case histories and performing examinations, have proven themselves to be core elements of effective tutor training.

[Learning objectives for psychosomatic medicine and psychotherapy in light of the National Competency-Based Catalogue of Learning Objectives for Medicine (NKLM)]. / Lernziele der Psychosomatischen Medizin und Psychotherapie vor dem Hintergrund des Nationalen Kompetenzbasierten Lernzielkataloges Medizin (NKLM).

OBJECTIVE: The "National Competency-Based Catalogue of Learning Objectives for Medicine" ("Nationaler Kompetenzbasierter Lernzielkatalog Medizin,"NKLM) is a core curriculum developed for medical training. Here, the classic division by discipline and organ system has been abandoned, which requires each discipline to define its own core curriculum in specific catalogues of learning objectives. This article presents such a catalogue for Psychosomatic Medicine and Psychotherapy. METHOD: A two-step DELPHI-method was used to survey faculty representatives for Psychosomatic Medicine and Psychotherapy. It reflected the discipline-specific university catalogues of learning objectives as well as the NKLM. A catalogue of learning objectives was then developed and approved. RESULTS: The catalogue consists of two parts: (1) a 12-module core curriculum for Psychosomatic Medicine and Psychotherapy and (2) selected interdisciplinary learning objectives from the NKLM with relevant participation of the discipline in ten modules. DISCUSSION: For the first time in Germany, this article presents a catalogue of learning objectives for Psychosomatic Medicine and Psychotherapy that is agreed upon by the relevant representatives. This enables the integration of psychosomatic and psychotherapeutic teaching contents from a department into the overall curriculum as required by the NKLM. In the future, methods should be established to allow regular updating and further development of this catalogue.