Can a 'rural day' make a difference to GP shortage across rural Germany?

INTRODUCTION: The 'Verbundweiterbildung(plus) Baden-Württemberg' (Verbundweiterbildung(plus)) - a structured general practice (GP) postgraduate training program - developed a 'rural day' as an intervention to ensure rural health exposure for GP trainees. This project report presents the outcome of the intervention: intention to work in a rural area. METHODS: At the time of the study, 500 GP trainees were enrolled in Verbundweiterbildung(plus). Invitations to complete an internet-based questionnaire were distributed by email to the 274 GP trainees who had previously been asked to participate in one of eight rural days. The questionnaire contained 4 generic and 10 specific items for participants in the rural days and 4 items specific to non-participants. Mixed-methods analyses were performed using the Statistical Package for the Social Sciences. RESULTS: Of the 274 GP trainees invited to complete the questionnaire, 38 of 80 rural day participants and 72 of 194 non-participants completed the questionnaire (overall response rate 40%). Participants and non-participants did not differ significantly regarding age, sex and origin. Nearly half of the participants claimed the rural day changed their overall attitudes towards rural areas positively. However, there was no significant difference in the intention to work in a rural area for participants before and after the rural day experience. CONCLUSIONS: The rural day increased positive attitudes towards rural areas in general but had no influence on intention to work in rural practice. More awareness and responsibility regarding workforce shortages in rural primary health care among political stakeholders, trainers and trainees is needed. Duration of the intervention should be extended and possibly complemented by offering rotations in rural practices to increase the effect. Enabling factors and barriers regarding working in rural areas are already known by political stakeholders, trainers and trainees and need to be more adequately addressed during GP postgraduate training.

Developing a seminar curriculum for the Competence Center for General Practice in Baden-Wuerttemberg - a progress report.

Aim: The seminar program of the KWBW Verbundweiterbildungplus® is offered by the Competence Center for Postgraduate Medical Education in Baden-Württemberg (KWBW) for physicians specializing in general practice (GP trainees). Attendance is a voluntary one comprised of 48 curricular units of 45 minutes each per GP trainee. This seminar program is meant to be attended in parallel to the postgraduate medical education in clinic or practice. The intention behind this project was to develop objectives, topics and a feasible structure for a seminar curriculum while taking time and financial constraints into account. Method: The Kern cycle was applied in an open, modified nominal group consensus technique in the form of an iterative process. Participating were 17 experts from the departments of general practice at the universities in Freiburg, Heidelberg, Tuebingen and Ulm, plus a pediatrician. Results: The main objective was defined as empowering GP trainees to independently provide high-quality primary care, including in rural areas. A basic curriculum was defined based on relevant frameworks, such as the 2018 Model Regulation for Postgraduate Medical Training (Musterweiterbildungsordnung/MWBO) and the Competency-based Curriculum General Practice (KCA). Overall, the seminar curriculum has 62 basic modules with 2 curricular units each (e.g. Basic Principles of General Practice, Chest Pain, Billing) and another 58 two-unit modules on variable topics (e.g. digitalization, travel medicine) adding up to 240 (124+116) curricular units. A blueprint with a rotation schedule for all of the teaching sites in Baden-Württemberg allows regular attendance by n=400 GP trainees over a period of five years, with individual variability in terms of program length. Conclusion: The model entails a five-year, flexible program to accompany the postgraduate medical education in general practice which can also be implemented in multicenter programs and those with high enrollments. The model's focus is on acquisition of core competencies for general practice. Despite the current shift to eLearning seminars due to SARS-CoV, the program's implementation is being continued, constantly evaluated, and used to further develop the KWBW Verbundweiterbildungplus® program.

Opportunities and challenges of e-learning in vocational training in General Practice - a project report about implementing digital formats in the KWBW-Verbundweiterbildungplus.

Background: The task of the Competence Centers for vocational training (KW) is to increase the attractiveness and quality of vocational (=post-graduate) training in general practice. For this purpose, they offer, among other things, a structured seminar program for post-graduate trainees in general practice (GP-trainees). During the Covid-19 pandemic the seminar program of the KWBW-Verbundweiterbildungplus® in Baden-Württemberg was converted to digital formats. The goal of the paper is to evaluate the acceptance by the GP-trainees and lecturers, to describe experiences with the conversion to e-learning and to derive recommendations with regard to the future orientation of seminar programs in post-graduate as well as continuing medical education. The implementation was based on a modified Kern-cycle and aimed at offering eight teaching units of 45 minutes each to a large number of GP-trainees. It tried to maintain the high quality of content and education as well as the interactive character of the previous seminars. For this purpose, the events were designed as synchronous webinars (six units) with asynchronous preparation and post-processing (two units) according to the flipped classroom method. The evaluation by the participating GP-trainees and lecturers was performed online using a multi-center developed and pre-piloted questionnaire. Results and discussion: N=101 GP-trainees participated in the evaluation of five individual seminar days in the second quarter of 2020 (response rate 97%). 58% (N=59) of the trainees were satisfied or very satisfied with the implementation. 82% (n=83) rated pre-tasks as helpful. 99% (n=100) would participate in an online seminar again. For 52% (n=53) of the trainees, the attitude towards e-learning had changed positively. The main advantages mentioned were no travel, save in time and costs as well as increased flexibility. The main disadvantages mentioned were less personal interaction and technical obstacles. The high acceptance of the new digital format showed the fundamental potential of e-learning in continuing medical education. The experiences can be a source of inspiration for other departments and KW. However, it also shows that important goals of KW, such as the personal interaction of the peer group, could not be achieved. In the future, it is important to develop a suitable mix of presence and digital formats with the aim to improve the attractiveness as well as sustainability of continuing medical education.

New paths in post-graduate medical training in general practice - 8 years of experience with the pilot project Verbundweiterbildungplus Baden-Württemberg.

Background: In face of the looming shortage of general practitioners, primary healthcare providers and post-graduate training in general practice are increasingly becoming part of the political agenda in Germany. In 2009 the program "Verbundweiterbildung plus Baden-Württemberg" (VWB plus BW) was developed by the Competence Center for General Practice in Baden-Wuerttemberg to ensure primary healthcare in the future by enhancing the attractiveness of general medicine. This paper describes the experiences that have been gathered in developing a post-graduate training-program for physicians undergoing specialist training in general practice. Project description: The Competence Center for General Practice in Baden-Wuerttemberg supports the organization of regional networks dedicated to post-graduate medical education. First core element of the VWB plus BW program is a special seminar series for physicians pursuing post-graduate training. This seminar program is aligned with the German competency-based curriculum in general medicine and is meant to promote medical expertise and other related competencies, such as business and medical practice management and communication skills. Mentoring and advising the physicians regarding professional and personal planning form the second core element. The third core element is seen in the train-the-trainer seminars that address the competencies of the trainers. In order to focus the program's content closely on the needs of the target groups, scientifically based evaluations and research are carried out. Results: Since starting in 2009, 685 physicians have entered the program and 141 have passed the examination to become medical specialists (as of December 2016). In total, 31 networks, 60 hospitals and 211 general practices have participated. The seminar sessions have been rated on average with 1.43 on a six-point Likert scale by the physician trainees (1=extremely satisfied, 6=extremely dissatisfied). Alongside the medical training, these physicians viewed the exchange of information and experiences with other physicians as very positive and important. In 185 seminars lasting 90 minutes each, the seminar program has presently covered 250 out of 320 units in the competency-based curriculum for general medicine. A total of 281 trainers have been trained in 13 train-the-trainer courses and have rated this course on average with 1.36 on a six-point Likert scale. Above all, the trainers emphasized the exchange of information and experiences with other trainers as very positive. In 2013 the DEGAM concept for its Verbundweiterbildungplus program was developed based on that of the VWB plus BW. Since 2008 over 40 articles on the topic of post-graduate medical education have been published. Conclusion: The steadily increasing number of participants over the years demonstrates that the VWB plus BW is relevant for recent medical graduates and contributes to the attractiveness of general practice. The consistently excellent evaluations of the training program and the train-the-trainer course affirm the focus on the needs of the target groups. The post-graduate VWB plus BW program advances structured, competency-based and quality-oriented specialist training and fosters professional sharing between physicians - something that could also be relevant for other fields. The increasing numbers of participating physicians and specialists in general practice in Baden-Württemberg lead to the conclusion that the VWB plus BW program positively influences the number of general practitioners.

[Prescription of generic drugs in general practice. Results of a survey of general practitioners]. / Verordnung von Generika in der hausärztlichen Praxis: Ergebnisse einer Befragung von Hausärzten.

BACKGROUND AND PURPOSE: Switching brand-name drugs to generics is reasonable and desired for economic reasons. Few data exist about problems, if any, during the switching in general practice. In this survey, the view of general practitioners (GPs) should be ascertained. METHODS: GPs in five counties in the German federal states Thüringen and Baden-Württemberg, who took part in a study on generic drug prescribing, were asked to complete a questionnaire about experiences and attitudes toward generic drug prescription. RESULTS: A total of 195 (84%) of 233 GPs answered the questionnaire. Two thirds (127/195) stated, that brands and generics are pharmacologically equivalent. Many of these GPs estimated to prescribe generic drugs in > 50% of instances; fewer doctors did so, if they had doubts as to the equivalence of generics (65% vs. 46%; p < 0.05). Nearly 8% reported generics being less effective, and 10% observed new adverse effects after switching. Many GPs appointed the following barriers: cooperation with hospitals and colleagues (86%), GP's lack of time (68%), and communication problems with the patient (50%). GPs estimated that > 10% of patients strictly reject generic drugs. CONCLUSION: An optimized cooperation between GPs and hospital physicians could facilitate the consumption of generic potential in pharmacotherapy. Reasons for the obvious contrast between the proven pharmacological equivalence of brand-name and generic drugs and the problems encountered after switching reported by GPs should be further studied.

Adaptation, psychometric properties and feasibility of the Professionalism Scale Germany.

INTRODUCTION: Pre- and postgraduate education is meant to be competency-based. Over the last two decades various competency frameworks have been published. An important aspect of competency is professionalism, being discussed widely in the literature while a clear-cut definition is still lacking. The purpose of this study was to translate the Nijmegen Professionalism Scale into the German language, to adapt the scale to the German setting and to examine the psychometric properties, test-retest reliability and feasibility of the culturally adapted instrument designed to assess professionalism in general practice, in addition to the validity of the concept of professionalism and to testify the transfer across linguistic, cultural and societal differences. METHOD: After translating the Nijmegen Professional Scale into German, we conducted its cultural adaptation, the German Professionalism Scale (Pro-D). Its psychometric properties were assessed using Cronbach's α, descriptive statistics, and test-retest reliability. The validation of the construct was analysed by confirmatory factor analysis. Feasibility was confirmed in interviews with GP trainees and their trainers. RESULTS: A total of 133 trainees completed the Pro-D. The Pro-D showed high internal consistency (Cronbach's α 0.93) and good test-retest reliability (Spearman's rank correlation and Wilcoxon's matched-pairs test) for the different domains. Confirmatory factor analysis was unable to establish construct validity. Change in sensitivity of the instrument was good. Statements of interviews confirmed the feasibility of the new instrument. CONCLUSIONS: We found good psychometric properties for the Pro-D. This might indicate transferability of the concept across linguistic, cultural and societal differences although the concept of professionalism was not replicated in a confirmatory factor analysis.

[Five-year experience with Train-the-Trainer courses for general practice trainers - a qualitative and quantitative analysis]. / Fünf Jahre Train-the-Trainer-Kurs für weiterbildungsbefugte Hausärzte - qualitativ-quantitative Analyse der Begleitevaluation.

BACKGROUND: A Train-The-Trainer course (TTT course) for general practice trainers was developed as part of the program Verbundweiterbildungplus Baden-Württemberg. The course included aspects of training such as organizational and legal knowledge as well as didactic skills for trainers in 9.5 teaching units (45minutes each). The present article analyzes the evaluation of the course and considers possible future developments for TTT courses in Germany. METHODS: An evaluation tool was used covering aspects such as information, relevance for daily work, opportunities for participant engagement in the seminars and working environment as well as didactic competencies among teachers. Within five years, 256 trainers participated in a TTT course and received an evaluation sheet. Data were analyzed descriptively. RESULTS: 249 evaluation sheets were included (response rate 97 %). Overall, the participants were (very) satisfied with the course in general, its organization, the exchange with colleagues and the teaching units. The participants used the free text mode to give positive feedback; in particular, teaching units in organizational and legal regulations as well as practical feedback training to strengthen professionalism were evaluated positively. Suggestions for improvements included follow-up courses or a deepening of understanding of course contents. CONCLUSION: The participants gave a very positive overall rating and claimed to have benefited from the course contents. Future projects should address further qualifications of general practice trainers and facilitate the exchange with colleagues on an ongoing basis.

[Verbundweiterbildung(plus) Baden-Württemberg: Development of educational meetings and implications for the implementation of family medicine training programmes in Germany]. / Das Schulungsprogramm der Verbundweiterbildung(plus) Baden-Württemberg: Entwicklung und Implikationen für die Implementierung von Verbundweiterbildungsprogrammen in Deutschland.

BACKGROUND: The German Society of General Practice and Family Medicine (DEGAM) has defined educational seminars during post-graduate training as a core element to improve trainees' specific knowledge and competencies. Furthermore, these seminars facilitate networking among trainees and support the process of identity formation in family medicine. Since its implementation in 2009, the Verbundweiterbildung(plus) Baden-Württemberg (VWB(plus) Ba-Wü) has offered educational seminars. Aim of this article is to analyse the content of these educational seminars and to derive implications for other family medicine training programmes in Germany. METHODS: From 2009 to 2015, the data from all educational seminars was descriptively analysed. Furthermore, two researchers categorised the seminar contents independently of each other and assigned them to the competence-based curriculum for family medicine training (Kompetenzbasiertes Curriculum Allgemeinmedizin, KCA). RESULTS: Until 2015, 600 trainees participated in a starter seminar of the VWB(plus) Ba-Wü. In total, 1,116 teaching units and 160 different seminars covered all relevant topics of the KCA. A restructuring of organisational processes and seminars was necessary to handle the increase in the number of participants, including the development of specific software for electronic support. Of all these seminars, 56% were held by specialists or trainees in family medicine. The participating trainees rated the educational seminars in general and the possibility for networking as (very) good. CONCLUSIONS: The contents of the educational seminars included in family medicine training programs will have to be specifically based on family medicine and cover all relevant aspects of the KCA - medical expertise, competencies and procedures. In order to ensure a common standard concerning didactic methods and qualifications of teachers, a didactic guideline is to be developed. The increasing demand of family medicine training programmes requires (further) development of the software eSchoolab, including integration of the KCA.

Assessing family medicine trainees--what can we learn from the European neighbours?

BACKGROUND: Although demands on family physicians (FP) are to a large extent similar in the European Union, uniform assessment standards for family medicine (FM) specialty training and assessment do not exist. Aim of this pilot study was to elicit and compare the different modalities and assessment methods of FM specialty training in five European countries. METHODS: A semi structured survey was undertaken based on a convenient sample in five European countries (Denmark, Germany, Poland, the Netherlands and the United Kingdom). The respondents were asked to respond to ten items about aspects of FM specialty training and assessment methods in their respective countries. If available, this data was completed with information from official websites of the countries involved. RESULTS: FM specialty training is performed heterogeneously in the surveyed countries. Training time periods range from three to five years, in some countries requiring a foundation program of up to two years. Most countries perform longitudinal assessment during FM specialty training using a combination of competence-based approach with additional formative and summative assessment. There is some evidence on the assessments methods used, however the assessment method used and costs of assessment differs remarkably between the participating countries. CONCLUSIONS: Longitudinal and competence-based assessment is the presently preferred approach for FM specialty training. Countries which use less multifaceted methods for assessment could learn from best practice. Potential changes have significant cost implications.

Competence-based curriculum development for general practice in Germany: a stepwise peer-based approach instead of reinventing the wheel.

BACKGROUND: Improving postgraduate medical training is one important step to attract more medical students into general practice. Keeping pace with international developments moving to competence-based curricula for general practice training, the aim of this project was to develop and implement such a curriculum in Germany. METHODS: A five-step, peer-based method was used for the curriculum development process including panel testing and a "test version" of the curriculum for the pilot implementation phase. The CanMEDS framework served as a basis for a new German competence-based curriculum in general practice training. Four curricula from European countries and Canada were reviewed and, following required cultural adaptions, key strengths from these were integrated. For the CanMEDS "medical expertise" element of the curriculum, the WONCA ICPC-2 classification of patient's "reason for encounters" was also integrated. RESULTS: Altogether, 37 participants were involved in the development process representing 12 different federal states in Germany, and including an expert advisor from Denmark. An official "test version" of the curriculum consisting of three parts: medical expertise, additional competencies and medical procedures was established. A system of self-assessment for trainees was integrated into the curriculum using a traffic light scale. Since March 2012, the curriculum has been made freely available online as a "test version". In 2014, an evaluation is planned using feedback from users of the test model as a further stage of the implementation process. CONCLUSIONS: The first German competence-based curriculum for general practice training has been developed using a pragmatic peer controlled approach and implementation is being trialed with a "test version" of the curriculum. This model project and its peer-based methodology may support competence-based curriculum development for other medical specialties both inside and outside Germany.

Video-assisted feedback in general practice internships using German general practitioner's guidelines.

INTRODUCTION: The planned modification of the Medical Licenses Act in Germany will strengthen the specialty of general practice. Therefore, medical students should get to know the daily routine of general practitioners during their academic studies. At least 10% of students should get the possibility to spend one quarter of the internship, in the last year of their academic studies, in a practice of family medicine. The demonstrated teaching method aims at giving feedback to the student based on video recordings of patient consultations (student-patient) with the help of a checklist. Video-feedback is already successful used in medical teaching in Germany and abroad. This feasibility study aims at assessing the practicability of video-assisted feedback as a teaching method during internship in general practice. TEACHING METHOD: First of all, the general practice chooses a guideline as the learning objective. Secondly, a subsequent patient - student - consultation is recorded on video. Afterwards, a video-assisted formative feedback is given by the physician. A checklist with learning objectives (communication, medical examination, a structured case report according to the guideline) is used to structure the feedback content. FEASIBILITY: The feasibility was assessed by a semi structured interview in order to gain insight into barriers and challenges for future implementation. The teaching method was performed in one general practice. Afterwards the teaching physician and the trainee intern were interviewed. The Following four main categories were identified: feasibility, performance, implementation in daily routine, challenges of the teaching concept.The results of the feasibility study show general practicability of this approach. Installing a video camera in one examination room may solve technical problems. The trainee intern mentioned theoretical and practical benefits using the guideline. The teaching physician noted the challenge to reflect on his daily routines in the light of evidence-based guidelines. CONCLUSION: This teaching method supports quality control and standardizing of learning objectives during the internship in general practice by using general practice guidelines. The use of a checklist enhances this method in general practice. We consider the presented teaching method in the context of the planned modification of the Medical Licenses Act is part of quality control and standardisation of medical teaching during general practice internships. In order to validate these presumptions, further, evaluation of this method concerning the learning objectives using the guidelines of general practice need to be carried out.

Train the Trainer for general practice trainer - a report of the pilot within the programme Verbundweiterbildung plus.

BACKGROUND: Since 2008 the Verbundweiterbildung(plus) programme of the Competence Centre General Practice Baden-Wuerttemberg offers continual improvement with regards to content and structure of general practice training. The programme uses the didactical concept of the CanMEDs competencies, which were developed in Canada, as a postgraduate medical training framework. Train the trainer (TTT)-programmes are an additional important element of these contentual optimisations of postgraduate training. Within this article we describe the conception and evaluation of the first TTT-workshop within the programme Verbundweiterbildung(plus). METHODS: The conception of the first TTT-workshop was influenced by results of a survey of general practitioner (GP) trainers and by experiences with teaching GP trainers involved in medical undergraduate teaching. A questionnaire was designed to get a self-assessment about organisational and didactic aspects oriented on the CanMEDs competencies of postgraduate medical training. In addition, the workshop was evaluated by the participants. RESULTS: The workshop lasted 12 teaching units and included the following elements: introduction into the CanMEDs competencies, feedback training, fault management, legal and organisational aspects of post graduate training. From the 29 participating trainers 76% were male and on average 57 years old. The evaluation showed a good to very good acceptance of the workshop. Initial self-rating showed the need of improving in the fields of determining learning objectives, providing formative feedback and incorporation of a trainee. Most trainers rated themselves as very good in procure CanMEDs competencies with the exclusion of the competencies "Manager" and "Scholar". CONCLUSION: A TTT-programme is an important method to improve GP training which has not been used in Germany so far. Such a GP TTT-programme should highlight especially training in providing feedback and teaching in management aspects. Results of this article add information that can be used for developing TTT-programmes also in other specialties.

[Vocational training in general practice in Germany: a nation-wide survey among trainees]. / Gebietsweiterbildung Allgemeinmedizin in Deutschland: Eine bundesweite Umfrage unter Ärztinnen und Ärzten in Weiterbildung.

BACKGROUND: The increasing shortage of (primary care) physicians in Germany is currently being discussed within and outside the profession. A national survey among general practice trainees aimed to explore their perspectives of vocational training (VT). METHODS: After translation, cultural adaptation and web implementation of the questionnaire of the "Vasco da Gama Movement," the survey was conducted during 2009. Descriptive analyses were performed. RESULTS: Among 436 participants (mean age 36 years, 64% female, 49 months of VT) discipline-specific ("medically diverse discipline", "one-to-one care", and "holistic approach"), but also gender-related (females: "compatibility with family life", males: "autonomy and independence", and "opportunities to start their own practice") aspects were important to their choice of career. Despite the heavy workload job satisfaction, but not salary satisfaction, was generally high. Participants rated the following general conditions and content of VT as important: "structured rotations", "rotations in hospitals", "management skills", "working in a local care setting and in a multidisciplinary team" (all>88%). CONCLUSIONS: These results provide clues to improving VT in General Practice with respect to organisation and content including the consideration of gender-related living conditions. Furthermore, improvement and further development of VT programmes should ideally be part of an area-wide, interdisciplinary and intersectoral approach.

[Perspectives and experiences of vocational trainers in General Practice: a survey in Baden-Wuerttemberg]. / Perspektiven und Erfahrungen weiterbildungsbefugter Ärzte für Allgemeinmedizin - eine Umfrage in Baden-Württemberg.

BACKGROUND: In order to ensure the delivery of primary care part of the vocational medical training must take place in the general practice setting. In Germany, this requires the authorization to provide general practitioner (GP) training. While in many countries specific qualification programmes for GP trainers are obligatory, this does not yet apply in Germany. The aim of this survey was to explore perspectives and experiences of GP trainers focusing on their needs in view of a possible qualification course. METHODS: A three-page questionnaire was developed and sent to all 1,780 GP trainers in the federal state of Baden-Wuerttemberg, Germany. RESULTS: Of the 1,780 GP trainers 656 responded (response rate: 37%), 18% of them being female trainers. About a quarter of the respondents had a vocational trainee, while 36% were looking for one at the time of the survey. The reason most frequently given for not having a vocational trainee was "no applicants" (n=323). Motivational reasons for involvement as a GP trainer were most commonly "interpersonal co-operation" (83%) and "enthusiasm for education" (69%). Only 2% of the respondents reported a bad experience with vocational trainees. Special needs were expressed regarding both legal and fiscal issues with vocational trainees in general practice and the development of a curriculum. CONCLUSIONS: For the first time the perspectives and experiences of GP trainers have been explored in the present study. The results may provide a basis for the development of a qualification programme for GP trainers in Germany.

["General Practice is a great job anyway" - a qualitative study with vocational trainees]. / "Allgemeinmedizin ist trotzdem ein schönes Fach" - eine qualitative Studie mit Ärzten in Weiterbildung.

BACKGROUND AND PURPOSE: Due to the increasing lack of physicians, an ageing and thus multi-morbid society and a misdistribution of physicians in Germany primary care provided by general practitioners is at risk. Therefore, approaches to recruit more physicians for general practice are being sought. The aim of the present study was to explore individual motivations for choosing a career in general practice, vocational trainees' perspectives on the current situation of vocational training and to identify possible approaches to improve the situation with suggestions from vocational trainees in Germany. METHODS: A qualitative study was conducted by interviewing 13 trainees. The interviews that were based on a predefined interview guideline were recorded and transcribed. The analysis was performed according to Mayring supported by the software Atlas.ti. RESULTS: In general, the reasons given for choosing general practice include the holistic view towards patients, the opportunity to see the direct impact of therapies and self-employment. Furthermore, general practice was perceived as a job with a positive work-life balance. Barriers to vocational training are the lack of structure of individual rotations and the low salaries during the rotation in practice. Furthermore, the basic conditions for working as a self-employed general practitioner in Germany were described as being a disincentive. A general suggestion for improvement was to promote professional recognition of general practice at universities. A qualification of vocational trainers was requested. Specific suggestions were: better payment, better-structured rotations and a specific preparation for the self-employed general practitioner. CONCLUSION: The results of this study reveal that a single measure is insufficient for recruiting more young doctors for general practice. In fact, a package of measures is necessary to improve aspects of the vocational training but also general conditions for the profession.

Communicable diseases prioritized for surveillance and epidemiological research: results of a standardized prioritization procedure in Germany, 2011.

INTRODUCTION: To establish strategic priorities for the German national public health institute (RKI) and guide the institute's mid-term strategic decisions, we prioritized infectious pathogens in accordance with their importance for national surveillance and epidemiological research. METHODS: We used the Delphi process with internal (RKI) and external experts and a metric-consensus approach to score pathogens according to ten three-tiered criteria. Additional experts were invited to weight each criterion, leading to the calculation of a median weight by which each score was multiplied. We ranked the pathogens according to the total weighted score and divided them into four priority groups. RESULTS: 127 pathogens were scored. Eighty-six experts participated in the weighting; "Case fatality rate" was rated as the most important criterion. Twenty-six pathogens were ranked in the highest priority group; among those were pathogens with internationally recognised importance (e.g., Human Immunodeficiency Virus, Mycobacterium tuberculosis, Influenza virus, Hepatitis C virus, Neisseria meningitides), pathogens frequently causing large outbreaks (e.g., Campylobacter spp.), and nosocomial pathogens associated with antimicrobial resistance. Other pathogens in the highest priority group included Helicobacter pylori, Respiratory Syncytial Virus, Varicella zoster virus and Hantavirus. DISCUSSION: While several pathogens from the highest priority group already have a high profile in national and international health policy documents, high scores for other pathogens (e.g., Helicobacter pylori, Respiratory syncytial virus or Hantavirus) indicate a possible under-recognised importance within the current German public health framework. A process to strengthen respective surveillance systems and research has been started. The prioritization methodology has worked well; its modular structure makes it potentially useful for other settings.