[Apps in General Medicine : A topic for medical education?​]. / Apps in der Inneren Medizin : Ein Thema für das Medizinstudium?

BACKGROUND: Health-related apps can provide helpful resources for both doctors and patients. The selection of potentially useful apps and the appraisal of their quality are particularly important in the context of medicine as false or confusing app content may put patients at risk. AIM: In this article a brief overview of the topic is provided and the results of a pilot study, in which medical students tested and evaluated the quality of 143 health-related apps on the topics of cardiology and pulmonology are presented. MATERIAL AND METHODS: Using the semiautomated retrospective app store analysis (SARASA) method, a group of apps concerned with cardiology and pulmonology were identified from a pool of over 2,000,000 apps available in the Apple Store. As part of a practical exercise, 138 4th year medical students tested a total of 143 of these apps, subsequently evaluating them using a specially devised questionnaire. RESULTS: The most frequent target population among the tested apps was identified as patients and their carers and the primary purpose in the majority of cases was the provision of information. Despite this, at least one quarter of all apps tested required users to enter sensitive health-related information. The evaluations by the students portrayed a large range in terms of the quality of the apps tested. DISCUSSION: Health-related apps play a growing role in the management of illnesses in the field of internal medicine. Doctors must be aware of the benefits and limitations of using such apps and should be prepared during their medical studies for the challenge of advising patients on this topic.

Effect of different scoring approaches upon credit assignment when using Multiple True-False items in dental undergraduate examinations.

INTRODUCTION: Various scoring approaches for Multiple True-False (MTF) items exist. This study aimed at comparing scoring results obtained with different scoring approaches and to assess the effect of item cues on each scoring approaches' result. MATERIALS AND METHODS: Different scoring approaches (MTF, Count-2, Count-3, "Vorkauf-Method," PS50 , Dichotomized MTF, "Blasberg-Method," Multiple response (MR), Correction for Guessing, "Ripkey-Method," Morgan-Method, Balanced Scoring Method) were retrospectively applied to all MTF items used within electronic examinations of undergraduate dental students at the University Medical Center Göttingen in the winter term 2016/2017 (1297 marking events). Item quality was evaluated regarding formal parameters such as presence of cues and correctness of content. Differences between scoring results of all scoring approaches and the differences between each methods' scoring results of items with and without cues were calculated by Wilcoxon rank sum tests (P < .05). RESULTS: Average scoring results per item highly differed between the scoring approaches and ranged from 0.46 (MR) to 0.92 (Dichotomized MTF). Presence of cues leads to significantly higher scoring in case of all scoring approaches (P < .001; +0.14 on average). However, effect of cues differed amongst scoring approaches and ranged from +0.04 (Dichotomized MTF) to +0.20 (MR). CONCLUSION: Scoring of MTF items is complex. The data presented in this manuscript may help educators make informed choices about scoring algorithms.

The effect of repeated testing vs repeated practice on skills learning in undergraduate dental education.

OBJECTIVES: Recent studies in undergraduate medical education have demonstrated the advantage of repeated testing over repeated practice with regard to knowledge and skills retention. The aim of this study was to investigate whether this "testing effect" also applies to skills retention in undergraduate dental education. METHODS: In this prospective, randomised controlled trial, fourth-year dental students at Göttingen University Medical Centre participated in a training session on surgical suturing in winter term 2014/2015. Following this, they were either assigned to two sessions of additional skills training (group A) or two sessions of skills assessment with feedback (group B). These sessions were spaced over a period of 4 weeks. Skills retention was assessed in a summative objective structured clinical examination (OSCE) at the end of term, that is 6 months after the initial teaching session. RESULTS: A total of 32 students completed the study. With regard to suturing, OSCE performance was significantly better in group B than group A (81.9±13.1% vs 63.0±15.4%; P=0.001; Cohen's d=1.33). There was no significant OSCE performance difference in the two groups with regard to other learning objectives that were addressed in the end-of-term examination. Thus, the group difference was specific to suturing skills. CONCLUSIONS: This is the first study to demonstrate that in dental education, repeated testing produces more favourable skills retention than repeated practice. Test-enhanced learning might be a viable concept for skills retention in undergraduate dentistry education.

Facilitators of high-quality teaching in medical school: findings from a nation-wide survey among clinical teachers.

BACKGROUND: Clinical teachers in medical schools are faced with the challenging task of delivering high-quality patient care, producing high-impact research and contributing to undergraduate medical education all at the same time. Little is known on the gap between an 'ideal' environment supporting clinical teachers to provide high quality teaching for their students and the reality of clinical teaching during worktime in the clinical environment. Most quantitative research published so far was done in a wide range of medical educators and did not consider individual academic qualifications. In this study, we wanted to survey clinical teachers in particular and assess the potential impact of individual academic qualification on their perceptions. METHODS: Based on qualitative data of focus group discussions, we developed a questionnaire which was piloted among 189 clinical teachers. The final web-based questionnaire was completed by clinical teachers at nine German medical schools. RESULTS: A total of 833 clinical teachers (569 junior physicians, 264 assistant professors) participated in the online survey. According to participants, the most important indicator of high quality teaching was "sustained student learning outcome" followed by "stimulation of interest in the subject matter". Lack of time was the main factor impeding effective teaching (78%). Among the factors facilitating high-quality teaching, protected preparation time during working hours (48%) and more recognition of high-quality teaching within medical schools (21%) were perceived as most helpful. Three out of four teachers (76%) were interested in faculty development programmes directed at teaching skills, but 60% stated they had no time to engage in such activities. With regard to evaluation, teachers preferred individual feedback (75%) over global ratings (21%). Differences between assistant professors and junior physicians were found in that the latter group perceived their teaching conditions as more difficult. CONCLUSIONS: Lack of time is a major barrier against planning and delivering good clinical teaching in medical schools. According to our findings, the situation at German medical schools is particularly challenging for junior physicians. Creating an institutional culture in which teaching is regarded as highly as patient care and research is a prerequisite for overcoming the barriers identified in this study.

[Response to and further development of the Choosing wisely initiative]. / Resonanz und Weiterentwicklung der Initiative Klug entscheiden.

The Choosing wisely initiative of the German Society of Internal Medicine ("Deutschen Gesellschaft für Innere Medizin," DGIM) and its 12 core focus area specialist societies were brought into being in 2014. The German initiative differs from the American campaign in that it not only considers overuse of diagnostic and therapeutic healthcare services, but also addresses procedures which are frequently not performed although they would bring benefits for patients. Furthermore, the recommendations were approved by an interdisciplinary consensus commission under consideration of all key internal medicine aspects. Since 2014, the initiative has received widespread attention. The 115 recommendations approved by the consensus commission have meanwhile been published in 20 articles. An array of measures were subsequently adopted to further promote the Choosing wisely recommendations ("Klug-entscheiden-Empfehlungen," KEE). These include the systematic incorporation of KEE symposia into DGIM annual congresses and the congresses of the core focus area specialist societies, as well as consideration of the KEE during establishment of future guidelines. Particular attention was paid to the importance of initiating and promoting a research project aimed at familiarizing medical students with the principles and content of the Choosing wisely initiative. The decision for or against specific diagnostic and therapeutic procedures represents an essential medical competence, which should therefore be trained prior to qualification.

How can we improve teaching of ECG interpretation skills? Findings from a prospective randomised trial.

BACKGROUND: There is an ongoing debate on how ECG interpretation should be taught during undergraduate medical training. This study addressed the impact of teaching format, examination consequences and student motivation on skills retention. METHODS: A total of 493 fourth-year medical students participated in a six-group, partially randomised trial. Students received three levels of teaching intensity: self-directed learning (2 groups), lectures (2 groups) or small-group peer-teaching (2 groups). On each level of teaching intensity, end-of-course written examinations (ECG exit exam) were summative in one group and formative in the other. Learning outcome was assessed in a retention test two months later. RESULTS: Retention test scores were predicted by summative assessments (adjusted beta 4.08; 95% CI 1.39-6.78) but not by the type of teaching. Overall performance levels and motivation did not predict performance decrease or skills retention. CONCLUSIONS: Summative assessments increase medium-term retention of ECG interpretation skills, irrespective of instructional format.

[Smoking cessation in patients with COPD]. / Tabakentwöhnung bei COPD.

Chronic obstructive pulmonary disease (COPD) is a leading cause of death worldwide. Cigarette smoking is the main cause of COPD. Quitting smoking is thus the most effective treatment strategy and central in COPD prevention. A number of guidelines on prevention, diagnosis, therapy and rehabilitation of COPD have been published. To help implementing and standardizing smoking cessation in COPD a guideline was published 2008 in Germany focusing on this complex issue. The present guideline is an update of the 2008 guideline and has a high grade of evidence (S3 according to the AWMF; Arbeitsgemeinschaft wissenschaftlicher medizinischer Fachgesellschaften). The guideline gives comprehensive and practical information on how to integrate smoking cessation as an central part of COPD therapy.

[Do final-year medical students know enough about the treatment of alcohol use disorders and smoking?]. / Wissen Studierende im Praktischen Jahr genug über die Behandlung der Alkohol- und Tabak-Abhängigkeit?

BACKGROUND AND OBJECTIVE: Smoking and alcohol use disorders (AUD) are associated with significant morbidity and mortality in Germany. However, it has recently been shown that German medical students in years 1 to 5 do not feel competent to treat patients who are addicted to tobacco or alcohol. This study examined whether these deficits are also prevalent in students in the final (sixth) year of training. METHODS: Students enrolled in the final year at University Medical Centre Hamburg-Eppendorf were invited to complete a questionnaire assessing smoking status and self-reported knowledge of health consequences of and treatment options for AUD and smoking as well as arterial hypertension and diabetes mellitus. Students were also asked to provide effectiveness estimates for different methods to treat AUD and smoking. RESULTS: A total of 228 out of 345 students participated in the survey (response rate 66 %). Smoking prevalence was 24 %. Approximately 90 % of students believed they knew how to treat arterial hypertension and diabetes mellitus, but less than a third thought they knew how to treat smokers and patients with AUD. Effectiveness ratings of treatments for the two addictive disorders revealed severe misconceptions. CONCLUSION: The deficits in undergraduate medical education regarding the treatment of addictive disorders reported for students from years 1 to 5 extend to students in the sixth year. Just before graduation, students still have severe knowledge gaps. In order to prevent tobacco- and alcohol-related deaths, medical school curricula need to be urgently improved.

Towards outcome-based programme evaluation: using student comparative self-assessments to determine teaching effectiveness.

BACKGROUND: Programme evaluation of medical education should be multi-dimensional. While structural and organisational aspects of teaching are frequently assessed, programme evaluation tools are rarely matched to specific learning objectives. AIMS: This study used one medical school's catalogue of specific learning objectives to implement and critically appraise a novel programme evaluation tool based on comparative student self-assessments. METHOD: Medical students enrolled in the clinical phase of the undergraduate curriculum in Göttingen were invited to self-rate their knowledge, skills and attitudes before and after each course. A newly developed formula controlling for student performance levels when entering a course was used to compute a percentage gain in knowledge, skills and attitudes. Data derived from a prospective, longitudinal intervention study on the development of electrocardiogram interpretation skills including 636 students from four consecutive cohorts were used to provide validity evidence of the new approach. RESULTS: The novel tool appeared superior to plain mean differences and effect sizes in detecting outstanding teaching as well as shortcomings of the curriculum. In addition, it adequately reflected objectively measured performance levels and was responsive to curriculum change. CONCLUSIONS: Comparative student self-assessment is a valid tool to appraise undergraduate medical curricula at the level of specific learning objectives.

[Preoperative smoking cessation in patients with lung cancer]. / Präoperative Tabakentwöhnung bei Patienten mit Bronchialkarzinom.

Successful smoking cessation is associated with a survival benefit for patients with lung cancer. However, smokers newly diagnosed with non-small cell lung cancer and scheduled for curative resection are frequently discouraged from stopping smoking in the immediate preoperative period. This recommendation is based on the results of one single prospective cohort study published in 1998 which reported an increased risk of perioperative pulmonary complications in patients undergoing non-thoracic surgery who had reduced their tobacco consumption within the two months leading up to the operation. During the past 12 years, numerous observational studies have investigated the impact of preoperative smoking cessation on perioperative risk for thoracic and non-thoracic surgery. However, no more than six studies included patients with pulmonary neoplasms. Owing to methodological limitations and considerable heterogeneity of the included patient groups, the existing data are insufficient to support or refuse any recommendation regarding cessation advice for patients during the immediate preoperative phase. In view of the post-cessation recovery time-course of pathophysiological alterations relevant to the occurrence of perioperative complications, a smoke-free preoperative interval of 2 - 6 weeks appears most favourable. However, this is difficult to achieve as a curative resection should not be postponed. Since there is no scientific evidence demonstrating a negative impact of preoperative smoking cessation on prognosis, patients newly diagnosed with lung cancer should be encouraged to make an attempt to quit while waiting for thoracic surgery.

Significant increase in factual knowledge with web-assisted problem-based learning as part of an undergraduate cardio-respiratory curriculum.

In recent years, increasing attention has been paid to web-based learning although the advantages of computer-aided instruction over traditional teaching formats still need to be confirmed. This study examined whether participation in an online module on the differential diagnosis of dyspnoea impacts on student performance in a multiple choice examination of factual knowledge in cardiology and pneumology. A virtual problem-based learning environment for medical students supervised by postgraduate teachers was created. Seventy-four out of 183 fourth-year medical students volunteered to use the online module while attending a 6-week cardio-respiratory curriculum in summer 2007. Of these, 40 were randomly selected to be included (intervention group); the remaining 34 served as an internal control group. Analysis of all written exams taken during the preceding term showed that both groups were comparable (86.4 ± 1.1 vs. 85.9 ± 1.1%; p = 0.751). Students in the intervention group scored significantly higher in the final course assessment than students allocated to the control group (84.8 ± 1.3 vs. 79.5 ± 1.4%; p = 0.006; effect size 0.67). Thus, additional problem-based learning with an online module as part of an undergraduate cardio-respiratory curriculum lead to higher students' scores in an exam testing factual knowledge. Whether using this teaching format increases overall student motivation to engage in the learning process needs to be further investigated.

Web-based collaborative training of clinical reasoning: a randomized trial.

BACKGROUND: Clinical reasoning skills are essential for medical practice. Problem-based collaborative learning via the internet might prove useful in imparting these skills. AIM: This randomized study assessed whether web-based learning (WBL) is superior to face-to-face problem-based learning (PBL) in the setting of a 6-week cardio-respiratory course. METHODS: During winter term 2007/08, all 148 fourth-year medical students enrolled in the 6-week course consented to be randomized in small groups to diagnose a patient complaining of dyspnoea either using a virtual collaborative online module or a traditional PBL session. Clinical reasoning skills were assessed by means of a key feature examination at the end of the course. RESULTS: No significant difference between the mean scores of both study groups was detected (p = 0.843). In virtual learning groups, costs for diagnostic tests were significantly correlated to the number of contributions to online group discussions (r = 0.881; p = 0.002). Evaluation data favored traditional PBL sessions over virtual collaborative learning. CONCLUSION: While virtual collaborative learning was as effective as traditional PBL regarding the acquisition of clinical reasoning skills, it was less well accepted than traditional PBL. Future research needs to determine the ideal format and time-point for computer-assisted learning in medical education.

Slow breathing reduces sympathoexcitation in COPD.

Neurohumoral activation has been shown to be present in hypoxic patients with chronic obstructive pulmonary disease (COPD). The aims of the present study were to investigate whether there is sympathetic activation in COPD patients in the absence of hypoxia and whether slow breathing has an impact on sympathoexcitation and baroreflex sensitivity. Efferent muscle sympathetic nerve activity, blood pressure, cardiac frequency and respiratory movements were continuously measured in 15 COPD patients and 15 healthy control subjects. Baroreflex sensitivity was analysed by autoregressive spectral analysis and the alpha-angle method. At baseline, sympathetic nerve activity was significantly elevated in COPD patients and baroreflex sensitivity was decreased (5.0+/-0.6 versus 8.9+/-0.8 ms.mmHg(-1)). Breathing at a rate of 6 breaths.min(-1) caused sympathetic activity to drop significantly in COPD patients (from 61.3+/-4.6 to 53.0+/-4.3 bursts per 100 heartbeats) but not in control subjects (39.2+/-3.2 versus 37.5+/-3.3 bursts per 100 heartbeats). In both groups, slow breathing significantly enhanced baroreflex sensitivity. In conclusion, sympathovagal imbalance is present in normoxic chronic obstructive pulmonary disease patients. The possibility of modifying these changes by slow breathing may help to better understand and influence this systemic disease.

[Passive smoking--health consequences and effects of exposure prevention]. / Passivrauchen: Gesundheitliche Folgen, Effekte einer Expositionskarenz und Präventionsaspekte.

Passive smoking is the third leading but preventable cause of death worldwide. It is associated with an elevated risk of developing acute respiratory diseases, obstructive lung disorders, lung cancer, and cardiovascular disease. Whereas the dose-response relationship between second-hand smoke exposure and respiratory diseases is likely to be linear, a non-linear dose-response curve has been observed with respect to acute cardiovascular events. This explains the disproportionately high risk of myocardial infarction among passive smokers as compared to unexposed individuals. Over the last ten years, exposure to second-hand smoke has declined in Germany, but it is still substantial. With passive smoking in the home being a difficult target for preventive measures, public smoking bans have recently been shown to greatly reduce second-hand smoke-related morbidity and mortality. In addition, such measures are usually well tolerated and highly relevant regarding legal aspects related to workplace issues. This article summarises the current evidence on the health consequences of passive smoking and on the favourable effects of public smoking bans.

[Smoking, chronic obstructive pulmonary disease and lung cancer]. / Tabakrauchen, chronisch obstruktive Lungenerkrankung und Lungenkarzinom.

Smoking is the main risk factor for chronic obstructive pulmonary disease (COPD) and lung cancer. Being a chronic disease, COPD severely impairs the quality of life. Lung cancer is the leading cause of death among German males and the third most important cause of death among German females. This review gives data on the primary prevention of both diseases and the beneficial effects of smoking cessation following disease manifestation. Smoking-induced oxidative stress triggers a chronic inflammation which is central to the pathogenesis of COPD. Smoking causes lung cancer by oncogenic mutations as well as inhibition of tumour-supressor genes. Women have an increased risk to develop COPD and lung cancer as compared to men when exposed to the same amounts of tobacco smoke. Smoking cessation is the only treatment capable of reducing exacerbations and mortality as well as sustainedly improving lung function. The high level of nicotine dependence in COPD patients mandates an intensive smoking cessation treatment including pharmacotherapy and psychosocial intervention. In patients with lung cancer, smoking cessation has confirmed favourable effects on body weight, performance status, postoperative complications and mortality. Thus, smoking cessation should be an integral part of lung cancer treatment. Further research is needed to better delineate the effects of smoking cessation in relation to other treatment modalities.

[Misleading information on smoking in German medical textbooks]. / Fehlinformation zum Tabakrauchen in deutschen Medizin-Lehrbüchern.

BACKGROUND AND OBJECTIVE: Smoking is a major risk factor for coronary heart disease and lung cancer. While nicotine causes addiction, heart and lung diseases are caused by other substances contained in tobacco smoke. This study assessed whether these facts are adequately portrayed in German medical textbooks. METHODS: The sections on cardiovascular and lung cancer risk factors in 28 German textbooks of internal medicine, available in two bookstores as well as the library of Göttingen University (Germany), were scanned for the words "smoking" and "nicotine" as risk factors for coronary artery disease and lung cancer. RESULTS: In 12 of the 25 textbooks covering cardiovascular disease, smoking was mentioned as a risk factor for coronary artery disease; another 12 textbooks listed nicotine or nicotine addiction. In one textbook both terms were used. While smoking was referred to in all 21 textbooks that also discussed risk factors for lung cancer, nicotine was not mentioned in this context. CONCLUSION: Many German textbooks of internal medicine contain misleading terms for the health effects of smoking, which may influence the thoughts and possibly also the behaviour of their readers. The use of the words "smoking" and "nicotine" as synonymous within the context of cardiovascular risk factors, suggesting a causal relationship between nicotine and coronary heart disease, is incorrect and should be removed from the specialist medical literature.

[Smoking and pulmonary diseases, positive effects of smoking cessation]. / Rauchen und pneumologische Erkrankungen, positive Effekte der Tabakentwöhnung.

More than 30 % of the German population are regular smokers, over half of whom will eventually die of smoking-related diseases. Life expectancy is abridged by 10 years in smokers compared to non-smokers. Smoking tobacco is the main risk factor for lung cancer and chronic obstructive pulmonary disease (COPD) and predisposes to a number of other lung diseases. A smoking cessation programme including pharmacological as well as psychosocial support is highly effective in COPD Patients. Smoking cessation improves lung function, symptoms and mortality. In conclusion, smoking cessation services are among the most effective medical interventions. Thus, a sufficient supply of smoking cessation services on a population level must be ensured.