[Non-medical aspects in the care for multimorbid patients in general practice. What kind of support and cooperation is desired? Focus groups with general practitioners in Berlin]. / Nichtmedizinische Aspekte der Versorgung multimorbider Patient*innen in der Hausarztpraxis. Welche Unterstützung und Kooperationen werden gewünscht? Fokusgruppen mit Berliner Hausärzt*innen.

BACKGROUND: General practitioners (GPs) are the first point of contact and they coordinate the care for multimorbid patients. This article discusses possible solutions for GPs' needs and wishes regarding the support for non-medical issues, in particular social and legal tasks as well as the cooperation with already existing institutions. METHODS: In the third study phase of a mixed-methods approach, two focus groups with eleven GPs from Berlin were carried out. The project is part of the NAVICARE project, funded by the federal Ministry of Education and Research. The focus groups were analyzed using the framework analysis. RESULTS: GPs caring for multimorbid patients are often faced with non-medical patient needs and social consultation issues. They would like to receive support in these areas and want more cooperative care structures. They are largely unaware of existing offers by social institutions in their city districts. The designation of a fixed contact person in social institutions could improve communication and thus enable low-threshold access. DISCUSSION AND CONCLUSION: The GPs agree that there is a need for support with social and legal matters in general practice. The focus groups discussed already existing offers that GPs could use more frequently and how a cooperation with providers of social care could succeed. GPs in Berlin think that support and relief measures, in particular in the form of cooperation with institutions in the district that provide social and legal support, are both desirable and conceivable.

Train the trainer course for general practice trainers in ambulatory care: the Berlin model.

Objective: Demands for a stronger competence orientation of specialty postgraduate medical training require the expansion of the didactic qualifications of those responsible for postgraduate medical training. In the context of the foundation of the Berlin competence center for postgraduate general practice training, a train the trainer basic seminar was designed together with the Berlin chamber of physicians. The seminar aims to convey formal-legal aspects in close connection with the development of didactic competences of the general practice trainers. This article presents the didactic concept, focal points and the schedule of the one-and-a-half-day seminar to be able to adapt it to one's own context. Methodology: After the seminars, participants filled out an evaluation form. The questionnaire included the subjective experiences of increased competence, the relevance of the contents, and the satisfaction with the structure and methods of the seminar. The data were analyzed descriptively. Results: Since June 2018, 46 general practice trainers have participated in one of three train the trainer seminars. 97.6% of the participants were very satisfied or satisfied with the overall seminar and felt that the timeframe was right, 92.7% would recommend the seminar to colleagues. 68.3% fully agreed that by attending the seminar they were able to improve their didactic skills, 90% were confident that they could integrate what they had learned into their work as general practice trainers. 85.4% stated that they had reflected on their role as trainers. In particular, the atmosphere, the high degree of interactivity and the protected framework for collegial exchange were positively emphasized. Conclusion: Together with the Berlin chamber of physicians, we succeeded in designing a train the trainer seminar which, on the one hand, met the needs of the general practice trainers for clarification of formal-legal questions of their further training activities and, on the other hand, allowed the further development of didactic skills. At the moment, a modular program is being planned in order to give general practice trainers the opportunity to expand their didactic competence and regularly exchange ideas with colleagues.

10 years of didactic training for novices in medical education at Charité.

Introduction: Many medical faculties are introducing faculty development programmes to train their teaching staff with the aim of improving student learning performance. Frequently changing parameters within faculties pose a challenge for the sustainable establishment of such programmes. In this paper, we aim to describe facilitating and hindering parameters using the example of the basic teacher training (BTT) course at the Charité - Universtitätsmedizin Berlin (Charité). Project description: After sporadic pilot attempts for university education training, basic teacher training was finally established at the Charité in 2006 for all new teaching staff. An interdisciplinary taskforce at the office for student affairs designed the programme according to the Kern cycle of curriculum development, while the Charité advanced training academy provided the necessary resources. Within ten years more than 900 faculty members have completed the BTT (9% of current active teaching staff at the Charité). The BTT programme underwent several phases (piloting, evaluation, review, personnel and financial boosting), all of which were marked by changes in the staff and organizational framework. Evaluations by participants were very positive, sustainable effects on teaching could be proven to a limited extent. Discussion: Success factors for the establishment of the programme were the institutional framework set by the faculty directors, the commitment of those involved, the support of research grants and the thoroughly positive evaluation by participants. More challenging were frequent changes in parameters and the allocation of incentive resources for other, format-specific training courses (e.g. PBL) as part of the introduction of the new modular curriculum of the Charité. Conclusion: The sustainment of the programme was enabled through strategic institutional steps taken by the faculty heads. Thanks to the commitment and input by those at a working level as well as management level, the basic teacher training course is today an established part of the faculty development programme at the Charité.

Faculty Development for Small-Group-Teaching with Simulated Patients (SP) - Design and Evaluation of a Competency-based Workshop.

Objective: The introduction of innovative teaching formats and methods in medical education requires a specific didactic training for teachers to use complicated formats effectively. This paper describes preliminary considerations, design, implementation and evaluation of a skills-based workshop (7,5 hours long) for teaching with simulated patients. The aim is to describe the essential components for a lasting effect of the workshop so that the concept can be adapted to other contexts. Method: We present the theoretical framework, the objectives, the didactic methodology and the implementation of the workshop. The evaluation of the workshop was carried out using questionnaires. First the participants (teachers of the faculty of medicine, clinical and science subjects) were asked to estimate how well they felt prepared for small group teaching immediately after workshop. Later, after some teaching experience of their own, they gave feedback again as a part of the general evaluation of the semester. Results: In the course of three years 27 trainings were conducted and evaluated with a total of 275 participants. In the context of semester evaluation 452 questionnaires were evaluated on the quality of training. Conclusion: The evaluation shows that participants appreciate the concept of the workshop and also feel sufficiently well prepared. As a limitation it must be said that this is so far only the lecturers' self-assessment. Nevertheless, it can be stated that even a one-day workshop with a stringent teaching concept shows long term results regarding innovative teaching methods.

Adherence to Trained Standards After a Faculty Development Workshop on "Teaching With Simulated Patients".

Background: Nowadays, faculty development programs to improve teaching quality are considered to be very important by medical educators from all over the world. However, the assessment of the impact of such programs rarely exceeds tests of participants' knowledge gain or self-assessments of their teaching behavior. It remains unclear what exactly is expected of the attending faculty and how the transfer to practice may be measured more comprehensively and accurately. Method: This study evaluates how specific teaching standards were applied after a workshop (10 teaching units) focusing on teaching communication skills with simulated patients. Trained observers used a validated checklist to observe 60 teaching sessions (held by 60 different teachers) of a communication skills course integrating simulated patients. Additionally, we assessed the amount of time that had passed since their participation in the workshop and asked them to rate the importance of communication and social skills in medical education. Results: The observations showed that more than two thirds of teaching standards were met by at least 75% of teachers. Fulfillment of standards was significantly connected to teachers' rating of the importance of communication and social skills (tb =-.21, p=.03). In addition, the results suggest a slight decrease in the amount of fulfilled standards over time (r=-.14, p=.15). Conclusions: Teachers' adherence to basic teaching standards was already satisfying after a one-day workshop. More complex issues need to be re-addressed in further faculty development courses with a special focus on teachers' attitude towards teaching. In future, continuing evaluations of the transfer of knowledge and skills from faculty development courses into practice, preferably including pre-tests or control groups, are needed.

Changes and interactions of flourishing, mindfulness, sense of coherence, and quality of life in patients of a mind-body medicine outpatient clinic.

BACKGROUND: Stress-related, behavioral or chronic diseases require a holistic therapeutic approach. Mind-body medicine (MBM) uses the interaction between mind, body, behavior, and the environment to affect physical and psychological health and function. This integrative strategy can be applied in clinical settings, e.g., in an outpatient clinic, to improve well-being as well as clinical outcomes. We hypothesized an improvement of flourishing, mindfulness, sense of coherence, and quality of life through a comprehensive MBM program. In addition, we hypothesized correlations between the measures themselves as well as between the measures influenced by the intervention. METHODS: We conducted a longitudinal cohort study in an outpatient clinic setting (n = 48 patients, with various diagnoses). A questionnaire battery, consisting of SF-12, Flourishing Scale (FS, FS-D), Freiburg Mindfulness Inventory (FMI), and Sense of Coherence Scale (SOC9), was used and applied in a pre-to-post format over a period of 18 weeks. The intervention was a 12-week MBM group program, with 1 session of 7 h per week. RESULTS: The pre-post comparison of the measures showed significant improvements in psychological health, flourishing, mindfulness, and coherence. We were able to verify correlations between the measures themselves, apart from physical health. Coherence correlated with psychological health, influenced by the intervention. Further analyses showed associations between coherence, mindfulness, and flourishing. CONCLUSIONS: The MBM program improved measures of psychological health and decreased the level of suffering from chronic disease. MBM led to an improvement of disease coping and appraisal of individual ailments, thereby enhancing quality of life. Personal flourishing, coherence, and mindfulness seem to interact with each other.

Stress management and mind-body medicine: a randomized controlled longitudinal evaluation of students' health and effects of a behavioral group intervention at a middle-size German university (SM-MESH).

BACKGROUND: Student life can be stressful. Hence, we started a regular mind-body medical stress management program in 2006. By today, more than 500 students took part and evaluations showed significant results, especially with regard to a reduction of stress warning signals. For further analysis, we now decided to run a randomized controlled longitudinal trial. METHODS: Participating students at Coburg University were randomized into an intervention (n = 24) or a waitlist control group (n = 19). The intervention group completed 3 sets (pre/post/follow-up) and the control group 2 sets (pre/post) of self-administered questionnaires. The questionnaires included: SF-12 Health Survey, Perceived Stress Scale (PSS), Sense of Coherence (SOC-L9), Visual Analogue Scale (VAS) concerning stress, and the Stress Warning Signs (SWS) scale. Randomly selected participants of the intervention group were also queried in qualitative interviews. The intervention consisted of an 8 week stress management group program (mind-body medical stress reduction - MBMSR). Follow-up measures were taken after 6 months. RESULTS: Virtually, no drop-out occurred. Our study showed significant effects in the intervention group concerning SF-12 Mental Component Scale (p = 0.05), SF-12 Physical Component Scale (p = 0.001), VAS (in general, p = 0.001) and SWS (emotional reactions, p <0.001), underlined by qualitative results, which showed a higher quality of life. CONCLUSIONS: The effectiveness of an MBMSR program in a group of supposedly healthy students could be demonstrated. Findings suggest that stress management might be given importance at universities that care for the performance, the quality of life, and stress-health status of their students, acknowledging and accounting for the challenging circumstances of university life, as well as the specific needs of the modern student population.

A qualitative study on patients' and physicians' visions for the future management of overweight or obesity.

BACKGROUND: The management of obesity with its associated morbidity and mortality is a growing problem in primary care practices. Despite numerous recommendations in response to this challenge, weight management interventions still yield poor results. This is partly due to a discrepancy between physicians' and patients' understanding of the problem and possible solutions. OBJECTIVE: This study analyses patients' and physicians' visions for the future management of obesity. METHODS: Qualitative in-depth semi-structured interviews were performed. Physicians and patients were asked about their individual needs, experience and views regarding the management of obesity. Fifteen GPs and 15 overweight patients participated in this study. Interviews were transcribed and submitted to qualitative content analysis. RESULTS: The investigation reveals a high level of agreement between the two groups with regard to communication requirements for successful care. Both groups stressed the need for multimodal care concepts inside and outside of GP practices. Both also addressed the current overburdening of outpatient care structures in dealing with the management of obesity. CONCLUSION: Options should be developed for closer cooperation between GPs and support facilities inside and outside practices.

Motivational interviewing and shared decision making in primary care.

OBJECTIVE: The aim of this study was to assess general practitioners' (GP) readiness to involve obese patients in therapy decision making and to determine whether they integrate motivational interviewing techniques. METHODS: Fifty-eight preventive Check-up 35 encounters with overweight and obese patients in primary care were audio recorded in 12 GP practices. The use of motivational interviewing techniques was rated with the Behavior Change Counseling Index (BECCI). The involvement in medical decisions was rated with the Observing Patient Involvement Scale (OPTION). RESULTS: OPTION and BECCI scores were low (means=0.71 and 1.65), indicating minimal implementation of shared decision making and motivational interviewing in preventive encounters with these patients. GPs used more motivational interviewing for patients with a BMI>30 kg/m(2) than for those with a BMI<30 kg/m(2). Female GPs had significantly higher shared decision making scores, indicating that they prefer to involve patients in medical decisions. GPs differed significantly in their use of both approaches. CONCLUSIONS: Shared decision making and motivational interviewing, though known to be successful strategies in lifestyle counseling, are rarely used during obesity encounters in our sample of German GPs. PRACTICE IMPLICATIONS: GPs should be sensitized and trained in the application of these methods.

GPs' attitudes, objectives and barriers in counselling for obesity--a qualitative study.

BACKGROUND: Increasing prevalence of obesity worldwide requires providing support for many patients. GPs in particular, as long-term supervisors of patients, are asked to deliver care to those affected. OBJECTIVES: This qualitative study aimed at identifying GPs' perspectives on counselling overweight and obese patients. METHODS: To that end, semi-structured interviews were conducted in Berlin with GPs regarding their objectives and barriers in overweight care. Fifteen GPs participated; interviews were audio taped, transcribed and analysed using qualitative content analysis. RESULTS: Analysis showed a differentiated pattern of medical and psychosocial objectives in obesity treatment. Overall, it was seen that GPs wanted to play a relatively passive role in treatment of obesity. In particular, motivating patients was a key goal of primary care consultations; at the same time patients' lack of motivation was a main barrier to successful treatment. CONCLUSIONS: Care for obese patients is perceived as ineffective and frustrating. Recommended solutions include further education to improve GPs' communication techniques, e.g. to trigger patients' motivation.

[Check up 35: what benefits do general practitioners in Brandenburg see?]. / Die Gesundheitsuntersuchung: Welchen Nutzen sehen Brandenburger Hausärzte?

INTRODUCTION: The so-called "Check up 35" is a structured preventive examination to be conducted by primary care providers. Recent interviews have shown that expectations with regard to this examination vary among physicians; some of them expressed doubt that the consultation is useful at all. The aim of this study was to representatively examine Brandenburg's family physicians' attitudes towards this "Check up". METHODS: 50% of the family physicians listed in the data base of the Association of SHI Physicians were randomly selected to receive a mail questionnaire (n=748). Participation in the study was voluntary, the questionnaires were evaluated anonymously. The physicians were asked about both content and assumed benefit of consultations. RESULTS: The questionnaire was answered by 37% of the physicians (n=274). In 2008, 40 "Check ups" were conducted every three months. 96% of the physicians amended the standard programme with additional preventive examinations - most frequently serum creatinine measurements. In most of the respectively rated categories, they appreciate the usefulness of the examination. In contrast, they take a rather sceptical attitude towards the en bloc standard programme. DISCUSSION: The study shows that many family physicians are very critical of the "Check up 35"; in particular, this applies to the range of scheduled examinations. There are considerable variations in the individual shaping of the consultation process among the physicians. They use the "Check up" as a tool for individual prevention instead of limiting it to the reduced standardised screening as intended.

Locus of control, self-efficacy and attribution tendencies in obese patients - implications for primary care consultations.

BACKGROUND: To examine health- related locus of control, self- efficacy and attribution tendencies in obese patients and to discuss their impact on primary care consultations. MATERIAL/METHODS: 123 patients, showing a BMI >25 kg/m(2) and following a health Check up, rated questionnaires regarding health-related locus of control, self-efficacy and attribution tendencies concerning obesity. Physical health parameters like BMI, level of cholesterol, blood pressure and existing cardiovascular co morbidities were assessed by GPs. Statistical analysis were conducted using SPSSv16.0. RESULTS: Patients scored comparable to a norm- population on self- efficacy and the three dimensions of health related locus of control. Physical health parameters did not explain variance. Patients named mainly behavioral causes for their overweight; those with a BMI >30 kg/m(2) tend to attribute their bodyweight to genetically origins. CONCLUSIONS: In order to conduct individual tailored consultancies it is necessary to explore the individual beliefs and attitudes of patients of concern. It is suggested that locus of control and self- efficacy are obligatory issues to discuss in preventive encounters with these patients. GPs should be trained in techniques like motivational interviewing in order to encourage patients to take responsibility for their health and thus increase treatment outcome.