Implementation of a uniform nationwide medical licensing examination in general practice. A feasibility study.

Objective: A competency-based training of medical students that is adapted to the realities of care is required internationally and is being intended in Germany with the Master Plan for Medical Studies 2020. In order to test these competencies, the German National Institute for state examinations in Medicine, Pharmacy and Psychotherapy (IMPP) has developed a concept for the redesign of the final part of the medical licensing examination in Germany. It focuses on general and interprofessional healthcare in the examination with outpatients. The aim of this work is to assess the feasibility of the new final examination on the basis of pilot examinations in family practices and to derive further steps for the national implementation. Methods: Fourteen medical students in their internship year completed a full examination with patients aged 42 to 84 years. Examiners evaluated the examination performance using standardised evaluation forms. Feasibility was qualitatively assessed in terms of compliance with content and time limits, examination results, patient reflections, and implementation in the practice. Results: Students were able to complete all tasks within the given time frame. Based on the evaluation forms, the examiners assessed the performance of the students. Patients appreciated the structured course of the examination in the familiar location of their family practice. For the nationwide implementation of the examination, 2,500 examination practices are required for about 10,000 examinees per year. Four students can then be examined on two days per year in each practice. Conclusions: Oral-practical examinations with outpatients in general medical practices can be carried out successfully throughout the nation. An implementation of the examinations throughout Germany requires that medical studies are restructured and that this new curriculum is implemented as intended by the Master Plan for Medical Studies 2020. Furthermore, training and remuneration of examiners together with a legal framework for the new examination must be established.

Dealing with resistance and negative attitudes as barriers to the implementation of a longitudinal communication curriculum - a field report.

Background: The aim of the project "Communicative Competences of Physicians" (BMG) was the pilot implementation of a longitudinal model communication curriculum. For the Mainz project location, the task was to integrate courses offered in the clinical subjects into a communication curriculum and to expand it longitudinally. In this process, which was both content-related and social, resistance and negative attitudes regarding the continued development of the communication curriculum became apparent at an early stage. How these manifested and which measures were taken to overcome them is laid out in this reflective field report. Method/approach: At the beginning of the project, a SWOT analysis was used to identify the strengths and weaknesses that the faculty presented for the continued development of the communication curriculum. This assessment by the project staff included, among other things, an evaluation of the motivation levels of the faculty's lecturers and senior teaching staff. The subsequent specific, strategic and content-related planning of the further implementation steps in accordance with change-management concepts made it possible to take this aspect into account. For a more reliable assessment of the situation, the project was first presented to the faculty's teaching committee. In this situation it was possible to identify individuals with favourable and unfavourable attitudes. With the insight that was gained, the following course of action was decided upon: Contact advocates to gain their support. Contact the individuals with negative attitudes with the aim of building a relationship and arranging a personal meeting. Identify resistances and negative attitudes in one-on-one meetings and employ targeted countermeasures.Develop an action plan with a particular focus on gaining the cooperation of those who are essential to the success of integrating communication-related content into the major clinical disciplines. Results/experiences: In one-on-one meetings, it was possible to first clarify which learning objectives of communication training are already covered in the respective subject and which expertise is therefore available. Furthermore, it was possible to clarify which areas that were still absent in the overall communication curriculum should be taught in this clinical subject in particular. It became possible to involve the lecturers in the development in the spirit of participatory design. In accordance with the action plan, offers to support the development and organisation of as-yet absent portions of the curriculum were presented to the affected departments. Discussion/conclusion: Resistance and negative attitudes often do not represent a rejection of communicative competences - they rather express that teachers fear they do not have the expertise and resources to teach them. With the selected approach of outreach, personal conversation, and action plan, it was possible to provide the individuals in question with goal-oriented support.

[How do urological training residents experience the physician-patient conversation? : Promotion of communication competence in the context of medical residency training]. / Wie erleben urologische Weiterbildungsassistenten das Arzt-Patienten-Gespräch? : Förderung der Kommunikationskompetenz im Rahmen der ärztlichen urologischen Weiterbildung.

BACKGROUND: In urological continuing education, communication as a training content has not yet been offered in a structured way. Communication skills are already expected in the first year of training. OBJECTIVES AND METHODS: In the period from November 2017 to June 2018, a descriptive, multicentre cross-sectional study was conducted to identify the factors that promote and inhibit patient-oriented communication from the point of view of continuing training assistants in subject-specific situations (as-is analysis). For this purpose, modified focus groups were carried out in six urological departments with a total of 37 participants. The results were checked in a questionnaire analysis in 62 urological training assistants. RESULTS: The participants feel competent if they have sufficient specialist knowledge and experience, if it is a routine discussion situation and if they have sufficient time. They experience emotions, bad news and taboo topics as challenging. Facilitating factors are structural support at the workplace and support in the team. Aggravating factors are a lack of communication training, missing structures as well as a compression of the fields of work. They would personally benefit from mentoring, communication training and structured, interprofessional and interdisciplinary cooperation. CONCLUSIONS: This needs analysis provides a basis for the conception and elaboration of a communication curriculum. In this way, the overriding goal of promoting communication competence in urological continuing education can be achieved.

[Student assessments in palliative medicine as the cross-disciplinary subject 13: Survey of 34 medical faculties in Germany]. / Prüfungen im Querschnittsbereich Palliativmedizin (QB 13) : Befragung an 34 medizinischen Fakultäten in Deutschland.

BACKGROUND: In 2009 palliative medicine was integrated into the undergraduate curriculum as cross-disciplinary subject 13 and is now part of mandatory education in German medical faculties (MF). Surveys across German MFs have shown an inhomogeneous development of this cross-disciplinary subject. The aim of this study was to assess the current state and the needs in terms of assessments in the cross-disciplinary subject 13 at German MFs. MATERIAL AND METHODS: Palliative care coordinators at German MFs were surveyed by using a standardized telephone interview. Closed-ended questions were analyzed by descriptive analysis and open-ended questions by content analysis. RESULTS: A total of 34 out of 36 MFs participated. Multiple choice tests were the major form of assessment (94.1%) and 9 MFs planned to implement another form of assessment, mainly an objective structured clinical examination (OSCE) station (55.5%). The majority of the MFs (91.2%) had no blueprint to develop assessments but conducted a review (78.8%) afterwards. A successful implementation of the assessment was mostly achieved when the concept of the assessment was felt to be suitable. The lack of human resources was found to be the most relevant obstacle for the implementation of a practical assessment format. CONCLUSION: The major form of assessment in palliative care is still a written examination, especially multiple choice tests. This format is considered to be of limited value for assessing communicative competencies and attitudes in palliative medical care. Further steps should include the development of a competence-based assessment that is also feasible for smaller MFs with limited resources.

"Peer-assisted learning" (PAL) in the Skills-Lab--an inventory at the medical faculties of the Federal Republic of Germany.

BACKGROUND: Over multiple years, the didactic concept of "peer-assisted learning" (PAL) has proved to be valuable for medical education. Particularly in the field of the nowadays widely established Skills-Labs, the assignment of student tutors is both popular and effective. The aim of the underlying study is to assess the current status of PAL programs within German medical faculties' Skills-Labs regarding their distribution, extent, structure and content based on a nation-wide survey. METHODS: All 36 medical faculties in Germany were contacted and asked for their participation (via telephone or in written form) in the survey encompassing 16 central questions as to the structure of established PAL programs. Data obtained were subject to quantitative and qualitative analysis. RESULTS: 35 of 36 (97.2%) medical faculties participated in the survey. A PAL program was shown to be established at 33 (91.7%) faculties. However, the results show distinct differences between different faculties with respect to extent and content of the PAL programs. CONCLUSIONS: Among German medical Skills-Labs, PAL has been established almost ubiquitously. Further studies on the conception and standardization of training concepts appear to be pivotal for the advancement of PAL in the context of Skills-Labs.

[Do female medical graduates have different views on professional work and workload compared to their male colleagues? Results of a multicenter postal survey in Germany]. / Haben Frauen am Ende des Medizinstudiums andere Vorstellungen über Berufstätigkeit und Arbeitszeit als ihre männlichen Kollegen? Ergebnisse einer multizentrischen postalischen Befragung.

BACKGROUND AND AIM: This study investigated the career preferences of medical graduates with regard to discipline, final position, preferred area of work, and work load after the completion of postgraduate according to gender in Germany. METHODS: Standardized postal survey among all last year medical students in the medical faculties of Erlangen, Giessen, Hamburg, Heidelberg, Cologne, Leipzig and Magdeburg in 2009. 2017 persons were contacted and 1012 (48 %) participated. Descriptive statistics and regression analysis were performed. Qualitative interviews with graduates completed data collection. RESULTS: Overall, graduates prefer the hospital over private practice as their workplace after postgraduate training. However, 50 % of male graduates but only 29 % of female graduates aspire a leading position in the hospital. Male graduates often prefer careers in surgical disciplines, specialized internal medicine whereas female graduates orient themselves towards gynecology, pediatrics and smaller clinical disciplines like dermatology. 80 % of male but only 40 % of female graduates prefer a full-time position after completion of postgraduate training, whereas 16 % of female graduates aim at a part-time position only. CONCLUSION: The results demonstrate the persistence of traditional role models among medical graduates. Men aim at leading positions in the hospital whereas women prefer lower hospital positions or outpatient practices. Women look for part-time jobs, at least temporarily for child rearing whereas men continue to prefer full-time jobs.

Effects of a supplementary final year curriculum on students' clinical reasoning skills as assessed by key-feature examination.

BACKGROUND: The final year of medical education is considered crucial in making students 'fit for purpose'. Studies have shown that many students leave medical school without having experienced sufficient preparation for their upcoming professional life. AIM: The aim of this study was to examine the effectiveness of a supplementary internal medicine final year curriculum on clinical reasoning skills. METHOD: Final year internal medicine students from two universities participated in the study which was based on a static-group design. The experimental group (n = 49) took part in a final year student curriculum with interactive case-based seminars and skills training sessions. The comparison group (n = 25) did not receive any additional training beyond working on the ward. Clinical reasoning skills were assessed using a key-feature pre-post test. RESULTS: Prior to their clinical rotation, the two groups did not differ in the key-feature examination (p < 0.924). The experimental group performed significantly better than the comparison group (p < 0.028) in the post-intervention key-feature examination. CONCLUSIONS: Supplementary interactive case-based seminars and skills training sessions are effective and significantly improve the clinical reasoning skills of final year students in internal medicine. Further study is warranted and should look to examine the effectiveness of a final year student curriculum on other performance measures.

Cross-year peer tutoring on internal medicine wards: effects on self-assessed clinical competencies--a group control design study.

BACKGROUND: Peer-assisted learning (PAL) has become a well-accepted teaching method within medical education. However, descriptions of on-ward PAL programmes are rare. We introduced a PAL programme with a focus on clinical competencies on internal medicine wards. AIMS: To assess the effects of an on-ward PAL programme on self-assessed clinical competencies. METHOD: A total of 168 medical students were randomly assigned to one of the seven intervention wards or one of the seven control wards. During their 5-week ward-placement, the intervention group (IG; n = 88) received 10 patient-centred tutorials lead by final year tutors: (I) history taking, (II) physical examination, (III) blood withdrawal, (IV) infusion, (V) patient files, (VI and VII) ECG, (VIII-X) chart rounds. The control group (CG; n = 80) did not take part in the PAL programme. Clinical competencies were self-assessed pre- and post-intervention. RESULTS: For five of the ten assessed clinical competencies, increases in self-confidence ratings were significantly higher in the IG as compared to CG. CONCLUSIONS: RESULTS provide preliminary evidence to suggest that PAL programmes on internal medicine wards and with final year students as peer tutors may represent a valuable additional tool within medical clerkships. However, the findings must be confirmed and clarified in further research.

[Innovative teaching and examination methods--taking stock at German medical faculties]. / Einsatz innovativer Lern- und Prüfungsmethoden an den Medizinischen Fakultäten der Bundesrepublik Deutschland--Eine aktuelle Bestandsaufnahme.

BACKGROUND AND OBJECTIVE: Following amendment to the German medical licensing regulations in April 2002, the training and examination of clinical-technical competencies within university medical education has gained in importance. To date, the implementation of new and innovative teaching and assessment methods at medical faculties in the Federal Republic of Germany has not been subject to exhaustive and detailed evaluation. METHODS: Using structured telephone interviews, all 36 medical faculties were questioned concerning their curricula, application of skills laboratory training, standardised patients (SPs), problem-based learning (PBL), computer-based training (CBT), and the implementation of objective structured clinical examinations (OSCE). RESULTS: All 36 faculties (100 %) took part in the survey. 34 faculties (94 %) reported providing training in a skills laboratory and 30 (83 %) faculties reported working with standardised patients. PBL is employed at 33 faculties (92 %) and CBT at 32 (89 %). Practical clinical assessments in the form of OSCEs are conducted at 28 faculties and are currently being installed at two further universities. CONCLUSION: New and innovative teaching and examination methods have been implemented in almost all medical universities in the Federal Republic of Germany. Further studies are needed in order to assess the extent to which individual specialist fields are involved in these developments.

Ward rounds: how prepared are future doctors?

INTRODUCTION: Ward rounds are an essential activity for doctors in hospital settings and represent complex tasks requiring not only medical knowledge but also communication skills, clinical technical skills, patient management skills and team-work skills. The present study aimed to identify final year students' deficiencies in conducting ward rounds in order to aid the development of appropriate teaching tools. METHODS: 45 final year students participated in a simulated ward round session with three standardised patient scenarios: (1) myocardial infarction, (2) poorly controlled diabetes, and (3) acute fever in acute myeloid leukaemia. Videotaped sessions were rated by independent raters using binary item checklists which reflected predefined learning goals in five different domains: (I) information gathering, (II) communication with patient, (III) focused physical examination, (IV) chart reviewing/ prescription/ documentation and (V) team communication. RESULTS: For the three patient scenarios, 64.3% of the domain-specific learning goals were attained for the domain "information gathering", 79.4% for "communication with patient", 62.6% for "focused physical examination", 48.9% for "chart reviewing/ prescription/ documentation" and 86.0% for the domain "team communication". CONCLUSION: Final year students' ward round skills appear to be insufficient with a central deficit in reviewing charts and initiating appropriate prescriptions and documentation. Ward round training which eases the transition from observing ward rounds to conducting them on one's own is urgently required.

Guideline adherence for pharmacotherapy of chronic systolic heart failure in general practice: a closer look on evidence-based therapy.

BACKGROUND: There is robust evidence for effective pharmacotherapy of chronic (systolic) heart failure (CHF) which has led to the creation of guidelines, but many surveys evaluating CHF treatment show an under-utilisation of relevant drugs, while setting and patient population appear to be crucial for adequate appraisal of treatment patterns. AIMS: To evaluate the guideline adherence (GA) of general practitioners (GPs) in a well-defined patient population with CHF in primary care (PC). METHODS: A cross-sectional analysis was performed with the data of 167 patients enrolled in 37 GP practices (Germany) with documented left ventricular systolic dysfunction (LVEF: 33.3 +/- 6.9%). GA was assessed as usual (prescribing "yes" or "no"), through evaluation of target dosing, while adjusting for potential clinical contraindications, and through a modified Guideline Adherence Indicator-3 (mGAI-3), which assesses three relevant groups of substances according to New York Heart Association (NYHA) functional class: ACE-Inhibitors (ACE-I) or angiotensin receptor blockers (ARB), beta-blockers (BB) and aldosterone-antagonists (AA). RESULTS: Prescription rates for ACE-I/ARB, BB or both were 80%, 75% and 62%, respectively. The proportion of target doses reached for ACE-I was 16%, for BB only 8%. When adjusted for potential (mainly relative) contraindications (COPD, heart rate <60/min, hypotension, hyperkalaemia and renal dysfunction), the percentage of target doses reached increased to 49% for ACE-I/ARBs and 46% for BB. Application of the mGAI-3 showed moderate to perfect GA for usual assessment, proportion of target dose reached and adjusted in 83%, 16% and 55% of the patients, respectively. CONCLUSION: In the context of this patient and doctor setting, life-saving treatment was provided above average when assessed by usual criteria. The application of additional criteria showed further room for improvement. Future interventions aiming at optimisation should be tailored to the needs of doctors and patients likewise.

Integration of role-playing into technical skills training: a randomized controlled trial.

INTRODUCTION: Recently, efforts have been undertaken to enhance the face validity of technical skills training by introducing role-plays and standardised patients. Since little is known about the effects of role-playing with respect to the realism of a training situation and students' objective performance, we performed a randomized controlled trial. METHODS: 36 medical students participated in videotaped small group skills-lab sessions on the topics of Doppler sonography and gastric tube insertion. One half of the students participated in role-plays and the other half practised without role-playing. Realism of the training situation was analysed by means of post-intervention self-selected student survey evaluations. Technical performance and patient-physician communication were assessed by independent ratings of the videotaped sessions. RESULTS: The physician's role was regarded to be significantly more realistic when performing role-plays. Assessment of videotaped sessions showed that practising technical skills by performing role-plays resulted in significantly better patient-physician communication whereas students' technical performance did not differ between groups. CONCLUSION: Introducing role-plays enhances the realism of technical skills training and leads to better patient-physician communication. Students do not seem to be overstrained by practising clinical technical skills using role-plays. We conclude that role-playing is a valuable method in practising technical skills.

An innovative model for teaching complex clinical procedures: integration of standardised patients into ward round training for final year students.

OBJECTIVES: Ward rounds are an essential activity for doctors in hospital settings and represent complex tasks requiring not only medical knowledge but also communication skills, clinical technical skills, patient management skills and team-work skills. However, although the need for ward round training is emphasized in the published literature, there are currently no reports of ward round training in a simulated setting with standardized patients. METHODS: 45 final year students participated in a ward round training session lasting two hours with three standardized patient scenarios and role-plays. Final year students assumed the role of either doctor, nurse or final year student with role-specific instructions and provided each other with peer-feedback during the training session. Training was assessed using final year student focus groups and semi-structured interviews of standardized patients. Written protocols of the focus group as well as the interviews of standardized patients were content analysed. RESULTS: In the course of five focus groups, 204 individual statements were gathered from participating final year students. Ward round training proved to be a feasible tool, well accepted by final year students. It was seen to offer a valuable opportunity for reflection on the processes of ward rounds, important relevant feedback from standardized patients, peer group and tutors. Semi-structured standardized patient interviews yielded 17 central comments indicating that ward rounds are a novel and exciting experience for standardized patients. CONCLUSION: Ward round training with standardized patients is greatly appreciated by final year students and is viewed as an important part of their education, easing the transition from observing ward rounds to conducting them on their own.

An innovative model for final-year students' skills training course in internal medicine: 'essentials from admission to discharge'.

Clerkships are generally seen as a very favourable learning environment for final-year students. However, in recent years the clinical experience of final-year students has been reported to decline progressively. It was decided, therefore, to introduce an innovative skills training model in internal medicine. Sixty final-year students received four consecutive days of training during their first week, consisting of three-hour sessions on each day. The skills training course reflected a patient history from admission to discharge and included all required routine procedures, typical forms/files and computer interactions. Acceptability was measured with self-administered surveys post-intervention and again 16 weeks later; self-assessment was measured pre-/post-intervention. The skills training course was well accepted by the students and led to a significant improvement in self-assessment. It was considered to be very helpful for work on the wards in both the immediate and the long-term retrospective evaluation. The final-year skills training course allows students to learn how to handle specific tools and applications for their work on the ward. It possesses face validity and is easy to integrate.

Role-playing for more realistic technical skills training.

Clinical skills are an important and necessary part of clinical competence. Simulation plays an important role in many fields of medical education. Although role-playing is common in communication training, there are no reports about the use of student role-plays in the training of technical clinical skills. This article describes an educational intervention with analysis of pre- and post-intervention self-selected student survey evaluations. After one term of skills training, a thorough evaluation showed that the skills-lab training did not seem very realistic nor was it very demanding for trainees. To create a more realistic training situation and to enhance students' involvement, case studies and role-plays with defined roles for students (i.e. intern, senior consultant) were introduced into half of the sessions. Results of the evaluation in the second term showed that sessions with role-playing were rated significantly higher than sessions without role-playing.

[Integrated skills laboratory concept for undergraduate training in internal medicine]. / Integriertes Skills-Lab-Konzept für die studentische Ausbildung in der Inneren Medizin.

BACKGROUND AND OBJECTIVE: An amendment to the German medical curriculum in April 2002 will place basic practical skills at the centre of medical training. We report here on the implementation and evaluation of an obligatory, tutor-guided, and integrated skills laboratory concept in the field of internal medicine. METHODS: To test the effectiveness of a skills laboratory training on OSCE performance a pilot study was carried out. The experimental group, of 77 students, participated in seven sessions of communication training, skills laboratory training, and bedside teaching, each lasting one and a half hours. The control group of 66 students had as many sessions but was only offered bedside-teaching. The evaluation of acceptance of skills' training as well as the related increase in individual competence is on-going (summer term 2004: n = 176 students). RESULTS: The integrated skills laboratory concept was rated at 3.5 (SD = 1.2) on a 5-point scale and was acknowledged as practice-oriented (M = 4.2; SD = 1.0) and relevant for doctors' everyday lives (M = 3.6; SD = 1.1). Increased levels of competence according to individual self-evaluations proved to be highly significant (p<.001), and results of the pilot study showed that the experimental group had a significantly better OSCE performance than the control group (p<.001). CONCLUSION: This pilot study shows that curriculum changes promoting basic clinical skills are effective and lead to an improved practical education of tomorrow's physicians. The integrated skills laboratory concept is well accepted and leads to a relevant increase in competence in the practice of internal medical. The presented skills laboratory concept in internal medicine is proving to be a viable and efficient learning tool.

Intraepithelial photorefractive keratectomy for regression after laser in situ keratomileusis.

PURPOSE: To propose a refractive procedure, intraepithelial photorefractive keratectomy (IE-PRK), to treat regression after laser in situ keratomileusis (LASIK). SETTING: IMO Instituto de Microcirugîa Ocular de Barcelona, Cornea and Refractive Surgery Unit, Autonoma University of Barcelona, Barcelona, Spain; Vall d'Hebron Hospital, Department of Ophthalmology, INSERM, University Hospital, Toulouse, France. METHODS: This open but uncontrolled prospective pilot study assessed the efficacy, predictability, and stability of IE-PRK in 21 eyes of 21 patients who had previous LASIK for myopia or myopic astigmatism with a mean spherical equivalent (SE) refraction of -9.80 diopters +/- 2.95 (SD). After LASIK, the eyes regressed to a mean of -1.93 +/- 0.82 D. They were retreated with IE-PRK, in which a photoablation was performed directly in the epithelium without damage to Bowman's membrane. Follow-up was up to 1 year. RESULTS: Eight of the 21 eyes (38%) were emmetropic at 6 months and 11 (52.4%) had a refraction between -0.50 and +0.50 D. Refraction was stable from the second week to the first year, with no significant differences among the mean SEs at 10 days, 6 weeks, and 6 and 12 months. CONCLUSION: The preliminary results of this small series indicate that IE-PRK appears to be safe, especially in selected cases; 1 line of lost best spectacle-corrected visual acuity occurred in 5% of eyes.