Die Zukunftsprobleme der hausärztlichen Versorgung in Deutschland: Aktuelle Trends und notwendige Maßnahmen

More doctors, better health? A generalised synthetic control approach to estimating impacts of increasing doctors under Brazil's Mais Medicos programme

Worldwide, there are an insufficient number of primary care physicians to provide accessible, high-quality primary care services. Better knowledge on the health impacts of policies aimed at improving access to primary care physicians is important for informing future policies. Using a generalised synthetic control estimator (GSC), we estimate the effect of the increase in primary care physicians from the Programa Mais Médicos in Brazil. The GSC allows us to estimates a continuous treatment effects which are heterogenous by region. We exploit the variation in physicians allocated to each Brazilian microregion to identify the impact of an increasing Mais Médicos primary care physicians. We explore hospitalisations and mortality rates (both total and from ambulatory care sensitive conditions) as outcomes. Our analysis differs from previous work by estimating the impact of the increase in physician numbers, as opposed to the overall impact of programme participation. We examine the impact on hospitalisations and mortality rates and employ a panel dataset with monthly observations of all Brazilian microregion over the period 2008-2017. We find limited effects of an increase in primary care physicians impacting health outcomes - with no significant impact of the Programa Mais Médicos on hospitalisations or mortality rates. Potential explanations include substitution of other health professionals, impacts materialising over the longer-term, and poor within-region allocation of Mais Médicos physicians.

Physiotherapy-led care versus physician-led care for persons with low back pain: A systematic review

OBJECTIVE

To summarise the evidence on the effect of physiotherapy-led versus physician-led care on clinical outcomes, healthcare use, and costs in persons with low back pain.

DATA SOURCES

PubMed, Web of Science, CINAHL, Embase, and PEDro were systematically searched with the latest search performed in July 2024. Reference lists of articles were hand-searched.

REVIEW METHODS

Studies comparing clinical outcomes, healthcare use, or costs between adults with low back pain first consulting a physiotherapist and those first consulting a physician were included. Methodological quality was assessed with the Newcastle-Ottawa Scale. Study design, clinical setting, patient characteristics, and group effects were extracted. Findings on outcomes assessed in two or more studies were synthesised narratively. Certainty of evidence was determined using the GRADE approach.

RESULTS

Eighteen studies comprising 1,481,980 persons with low back pain were included. Most studies were non-randomised retrospective or prospective cohort studies. In primary care (15 studies), consistent evidence, though of mostly very low certainty, indicated that physiotherapy-led care leads to higher patient satisfaction, less use of medication, injections and imaging, fewer physician's visits, lower total healthcare costs, and less sick leave compared to physician-led care, without increased harm. In emergency care (three studies), evidence of very low certainty showed that physiotherapy-led care leads to shorter waiting and treatment times, and fewer hospital admissions.

CONCLUSION

Physiotherapy-led care is a clinically, time- and cost-effective care pathway for low back pain, although the certainty of evidence was overall very low. Further high-quality research with a greater focus on clinical outcomes is warranted.

Regional socioeconomic characteristics and density of general practitioners in Germany: A nationwide cross-sectional and longitudinal spatial analysis

OBJECTIVES

Limited healthcare availability impacts population health. Regional disparities in GP density across Germany raise questions about their association with regional socioeconomic characteristics.

STUDY DESIGN

This longitudinal nationwide ecological German study used regional data at the county level (n = 401) from 2015 to 2019 provided by the Federal Institute for Research on Building, Urban Affairs and Spatial Development (BBSR). The outcome was general practitioners (GPs) density, defined as the number of GPs per 10,000 inhabitants.

METHODS

Univariate Moran's I, cluster analysis (LISA), and spatial lag of X (SLX) models were employed to analyse the spatial distribution of GP density and its correlation with various regional socioeconomic characteristics from a cross-sectional and longitudinal perspective.

RESULTS

In contrast to the univariate analysis, rural counties showed the highest GP density the multivariate model. Several counties were identified as embedded in low- or high-GP-density clusters. In 2015 and 2019, larger household size (2015: std. β = -2.31, p = 0.021; 2019: std. β = -4.14, p < 0.001) and higher unemployment rate (2015: std. β = -2.84, p = 0.005; 2019: std. β = -5.47, p < 0.001) were associated with lower GP density. In the longitudinal model, a greater increase in the unemployment rate was related to a greater decrease in GP density (std. β = -2.17, p = 0.030).

CONCLUSION

A higher regional unemployment rate is linked to lower GP availability in Germany, and a greater increase in the unemployment rate was related to a greater decrease in GP availability over time. This necessitates policy intervention to avoid socioeconomic disparities in GP care.

[Ensuring primary care in Germany-findings from a quantitative survey of general practitioners]

BACKGROUND

Given the risk of a shortage of general practitioners in private practice, the question arises as to which concepts can make an effective contribution. To date, there is a lack of studies that comprehensively shed light on how general practitioners, based on their professional experience, view different approaches to ensuring primary care in the long term.

OBJECTIVES

The aim of the study was to determine the positions, attitudes, and experiences of general practitioners with regard to ensuring primary care.

METHODS

Using an online survey, a total of 4176 general practitioners were surveyed between February and June 2023. In addition to the descriptive analysis, a t-test on independent samples was used to determine significant differences between two groups.

RESULTS

Of those surveyed, 42% reported a noticeable decline of general medical practices in their area. In addition, 53% saw a declining attractiveness of primary care for young doctors, which is attributed to three problem areas: 1) the position of primary care in the healthcare system, 2) requirements for training and further education, and 3) working conditions. In order to secure primary care, those surveyed were primarily in favor of the following approaches: establishing a primary care physician system (85%), increasing the promotion of interest and points of contact in training and further education (80%), strengthening multi-professional outpatient care centers (64%), restructuring curricula (56%) and admission criteria for medical studies (50%), and reforming general medical training (53%).

CONCLUSIONS

As the results show, general practitioners have their own suggestions and preferences that complement existing expert assessments. General practitioners should be more consistently involved in the planning, implementation, and evaluation of measures to stabilize primary care.

Missing topics for a newly established general practice curriculum for medical students in Hesse - a qualitative study

BACKGROUND

To address the declining numbers of general practitioners (GPs) in rural areas and a lack of medical students pursuing a career in primary care, a general practice-based curriculum coupled with additional university admissions for students has been established at three universities in Hesse, Germany. This study aims to analyze potential topics which students striving to become a GP will benefit from. Teaching such topics will prepare them for their chosen career and working in rural areas. We aimed to explore the views of both specialists and GPs on chief topics and necessary skills in primary care.

METHODS

In our study we used semi-structured interviews with outpatient specialists and specialists in clinical practice and semi-structured group interviews with GPs in training. The topic guide addressed contents of the curriculum for medical students with an extracurricular focus (addressing additional topics) on primary care. Data analysis was carried out using qualitative content analysis according to Mayring.

RESULTS

GPs in training and specialists agreed on the importance of knowledge in the fields of medical history, physical examination, communication as well as common diseases in primary care. Essential competences mentioned were: inducing medical treatment, decision-making and triage, conducting structured conversations, having patient knowledge (hard skills) as well as an interest in continuous learning, empathy, personal commitment, listening and down-to-earthness (soft skills). Case reports, symptom-based learning, practical training, lessons with simulated patients and the integration of role models were regarded as useful teaching methods.

CONCLUSIONS

General practice-based curriculums should not only focus on the transfer of knowledge. Equally important is the training of soft and hard skills to prepare future GPs for their work in primary care. Special teaching methods as well as practical training should be the heart of a newly established curriculum.

[Ensuring Future Primary Care from a Municipal Perspective]

BACKGROUND

In view of the continuing shortage of general practitioners, ensuring access to (primary) medical care close to home is also becoming increasingly important for local authorities. The aim of the present study was to analyse the current and future provision of primary care from the viewpoint of the municipalities in North Rhine-Westphalia (NRW). From the results, it should be possible to derive future health policy design of a needs-based primary care close to home.

METHODS

In an online survey in spring 2023, we surveyed the mayors or representatives of health departments of all 427 municipalities (396 cities and communities, 31 districts) in NRW in cooperation with the NRW Association of Cities and Municipalities, the NRW Association of Counties and the NRW Association of Cities. The items of the questionnaire (n=28) were developed on the basis of two other surveys on medical care in Lower Saxony and Baden-Württemberg, each with a municipal policy target group. They were tested in repeated pretests.

RESULTS

In total, 192 municipalities participated in the survey (response rate: 45.0%). The majority of the municipalities (86.6%) considered the local provision of primary care to be (rather) not ensured within the next 10 years. The municipalities expressed the wish for more opportunities to exert their own influence (79.5% yes or rather yes), but nevertheless considered a stronger commitment, especially of the Associations of Statutory Health Insurance Physicians (85.4%), as well as an intensification of assumption of responsibility by the federal states (72.4%) to be necessary for ensuring primary care.

CONCLUSION

The survey shows that municipalities are quite aware of the problem of future deficits in the supply of general practitioners at the local level. The results also indicate that, in view of increasing supply shortfalls, the municipalities see obligations for the Associations of Statutory Health Insurance Physicians and the federal states to take responsibility and to exert greater political pressure in the future. The municipal perspective is an essential building block in considerations of how primary care can be ensured in the future. The responsible stakeholders should therefore involve the municipal level in the planning and measures to secure primary care more closely than in the past.

[Improving Postgraduate Medical Training In Germany: A Proposal]

Postgraduate (vocational, residency) training in Germany is regulated by the Physicians' Chamber in each federal state. Although training requirements are specified in detail by regulatory documents, young doctors are left on their own to find training posts and suitable learning experiences. There are no programmes in place to support trainees nor to identify the need of the health care system regarding the composition of its medical workforce. Hospitals and practices pay salaries to physicians in training from funding obtained for services they provide. We propose a systematic and continuing process of identifying gaps in the workforce. Disciplines with a lack of qualified doctors will be supported by additional funds directed to practices and hospitals. Regional rotation schemes will coordinate and improve the quality of training. Apart from an administrative overhead, this system of regulation will not need additional resources because a limited part of current budgets will be explicitly channelled into salaries for trainees in specialties for which there is a higher need than into others.

Attitudes towards career choice and general practice: a cross-sectional survey of medical students and residents in Tyrol, Austria

BACKGROUND

The global primary healthcare workforce is declining, leading to a shortage of general practitioners. Although various educational models aim to increase interest in general practice, effective interventions are limited. The reasons for this low appeal among medical graduates remain unclear.

METHODS

This cross-sectional study surveyed medical students' and residents' attitudes towards general practice in Tyrol, Austria. The online questionnaire addressed professional values, general practice-related issues, personal professional intentions, and demographics. Data analysis employed chi-square tests and multivariate logistic regression to explore predictors of interest in general practice.

RESULTS

The study included 528 students and 103 residents. Key values identified were stable positions, assured income, and work-family reconciliation. General practice was recognised for long-term patient relationships and patient contact, with students attributing more positive work-environmental characteristics and higher reputation to it than residents. Few participants (students: 3.2%, residents: 11.7%) had opted for general practice; about half were considering it as career option. Reasons not to choose general practice were preferences for other specialties, intrinsic characteristics of general practice, workload, insufficient time for the patients, financial pressures, low reputation, and perceived mediocre training quality. Predictors of interest in general practice included perception of independent decision-making, importance of work-family balance (students), better practical experiences in general practice during medical school (students and residents), younger age, and perceiving general practice as offering a promising future (residents). Both groups felt underprepared by medical school and/or general practice training for general practice roles. The attractiveness of specialist medicine over general practice was related to clearer content boundaries, better career opportunities, and higher incomes.

CONCLUSIONS

According to these results, measures to improve attractiveness of general practice should focus on (i) high-quality undergraduate education including practical experiences, and (ii) on ensuring professional autonomy, work-family reconciliation, and job stability. Efforts to encourage more graduates to pursue this essential healthcare sector are crucial for strengthening primary healthcare and public health services.

TRIAL REGISTRATION

The study has not been registered as it did not include a direct medical intervention on human participants.

[Interprofessional collaboration of general practitioners and nurses in primary care: A qualitative study]

Interprofessional collaboration of general practitioners and nurses in primary care: A qualitative study Abstract. Background: There is a need to strengthen interprofessional collaboration of general practitioners and home care nurses in the primary care of people with chronic diseases and long-term care needs. Aim: This study investigated a) how general practitioners and nurses in Germany perceive their collaboration in primary care and b) which development perspectives of collaboration exist from their point of view. Methods: Expert interviews were conducted with seven general practitioners and eight home care nurses. The data were analysed using thematic-structured qualitative content analysis. Results: The interviewees from both professional groups report that their collaboration is hindered by poor mutual accessibility. At the same time, they emphasise their appreciation of the professional exchange with the other professional group. Nevertheless, the perceptions of the professional competence of home care nurses differ. To improve their cooperation, the interviewees recommend the establishment of interprofessional meetings and cooperation in spatial proximity for regular professional exchange. They expect this to lead to a joint development of trust and competence and to an expansion of the area of responsibility of home care nurses in primary care. Conclusions: Binding communication structures, cooperation in spatial proximity and an expansion of the area of responsibility of home care nurses offer high potential for strengthening primary care in Germany.

[Between New Responsibility and Daily Routines - The Role of the VERAH in GP Care: A Qualitative Secondary Data Case Study of the Introduction of Software-Based Case Management]

BACKGROUND

The concept of Care Assistant in General Practice (VERAH) was developed in order to integrate non-medical staff more strongly into primary care and thus to meet the increasing demand for care and the simultaneous shortage of medical staff. VERAHs are increasingly responsible for software-supported case management and are thus confronted with new tasks. The aim of this study was therefore to explore the role of the VERAH in primary care practices.

METHODS

The present study is a qualitative secondary data analysis; the data collection took place within the projects VESPEERA and TelePraCMan. Twenty individual interviews and two focus group meetings were conducted with a total of 30 physicians, VERAHs and medical assistants from primary care. The data were analysed qualitatively according to Emerson. Contextual and socio-demographic data were collected with an accompanying questionnaire.

RESULTS

The VERAHs of all primary care practices from which interview partners participated performed tasks within software-supported case management. Concerning the role of the VERAH, three themes were identified in the interviews: a) concrete tasks of the VERAH in software-supported case management within the practice team, b) relevance of software-supported case management within the activities of the VERAHS and c) relationship between VERAHs and patients.

CONCLUSION

Taking over tasks in software-supported case management can contribute to strengthening and expanding the role of the VERAH. In the future, more attention should be paid to a clear description of the new role, and the conditions of the VERAHs' task fulfilment should be considered.

[Attitudes of general practitioners and medical practice assistants towards the delegation of medical services: Results of a survey in Berlin, Brandenburg and Thuringia]

INTRODUCTION

The delegation of tasks and responsibilities from general practitioners (GPs) to medical practice assistants (MPAs) can contribute to ensuring primary care in Germany. The aim of the study was to collect and analyze attitudes and procedures of GPs and MPAs regarding the delegation of physician-related tasks and activities.

METHODOLOGY

A self-designed, piloted questionnaire was sent to all GPs listed within the regional Associations of Statutory Health Insurance Physicians (KV) in Thuringia, Berlin, and Brandenburg (n=5,516) and their MPAs. Participants were asked to indicate which physician-related activities were already delegated and on which occasions further delegations could be considered.

RESULTS

890 GPs (response rate: 16.1%) and 566 MPAs participated in the written survey. The participants were predominantly female and most of them worked in urban areas. Numerous activities, such as medical history taking, triage, Disease Management Program (DMP) controls, vaccinations and home visits, have already been delegated. The willingness to delegate further tasks (e. g., follow-up prescriptions and referrals, independent takeover of simple consultations, assessing the necessity of physician consultation) was high.

CONCLUSION

The survey showed a high level of willingness of both occupational groups to delegate physician-related activities to MFAs. An expansion seems possible under certain conditions. Many activities have already been delegated to MPAs in primary care practices. Our survey provides suggestions regarding further tasks suitable for delegation, some of which go beyond the delegation agreement valid in Germany.

[Physician assistants as a future model in primary care: Experiences, needs, potentials and barriers]

INTRODUCTION

In the coming decades, demographic change will dramatically increase health care needs, especially for general practitioners (GPs). However, there is a shortage of young primary care physicians, with signs of (impending) underuse already becoming apparent in rural and structurally weak areas. Innovative care concepts are needed to counteract this development and ensure the future of primary care. In addition to medical assistants (MFA), academically trained physician assistants (PAs) could be considered for more demanding delegation tasks and be involved in direct patient care under the responsibility of a physician in the practice team. In England, the Netherlands and the USA, PAs have been a part of the health care systems for many years.

RESEARCH QUESTIONS

1) What are the potentials for delegation/possibilities for PAs working in primary care practices in contrast to medical assistants? 2) What structural requirements are necessary to regularly integrate PAs in primary care practices?

METHODS

After preliminary interviews with PA experts and primary care researchers and practitioners (n=29), four expert interviews (n=4) with GPs and PAs were performed in a case analysis in order to elicit experiences with PAs in family practice. Based on this, three focus groups were conducted with GPs and practice staff (n=15) to discuss the extent, the need and the willingness to delegate physician services to PAs, as well as existing barriers. After transcription, analyses were performed using qualitative content analysis according to Mayring.

RESULTS

The participants acknowledged the potential to reduce physician workloads and showed a high willingness to delegate tasks. Practical examples suggest that a clearly defined delegation of medical tasks to PAs, e.g. participation in infection consultations, is possible after only a few weeks working in family practices. Thus, the cooperation between GPs, PAs and medical assistants can be successful. Uncertainties exist regarding the legal possibilities and limits of delegation as well as the current and future financial reimbursement of PAs.

DISCUSSION

The legal and financial framework for the utilization of PAs in ambulatory care should be reliably clarified as well as transparently communicated so that the considerable potentials of delegating tasks to academically trained staff, e.g. PAs, especially in the GP sector, can be exploited in the future.

CONCLUSION

Participation of PAs in the GP team could be key to overcoming the often threatening or already existing under-provision of medical care in structurally weak regions.

Concept of a new Medical Data-Driven Health Care Model based on Remote Patient Monitoring

This paper introduces a health care model for a physician supervised remote monitoring process of patient's vital signs. The model is discussed from a process view, a medical view and a technical view. Subsequently, different scenarios for patients at home with and without outpatient care, and in a nursing home were compared. Parts of this model have been implemented and evaluated as a proof of concept.Clinical Relevance- Remote patient monitoring has the potential to relieve general practitioners in their work and help them to improve prevention and treatment of their patients. The prevention aspect in particular can contribute to a general reduction in the burden on the entire health care system.

What motivates GPs to train medical students in their own practice? A questionnaire survey on the motivation of medical practices to train students as an approach to acquire training practices

Background

With the new licensing regulations for doctors coming into force, medical faculties are faced with the task of recruiting and qualifying more GP colleagues to train students in their practices.

Objective

The aim of the study was to determine the motivation of GPs to train students in their own medical practices.

Method

A cross-sectional survey of Thuringian GPs was conducted from April to May 2020. 21 items on motivation, incentives and barriers were recorded and examined using univariate and multivariate analyses.

Results

The response rate was 35.8% (538/1,513). The GPs surveyed considered themselves motivated to train students in their medical practices. The motives can be described as predominantly intrinsic: the mutual exchange of knowledge, desire to share knowledge and to promote future doctors. Incentives included the opportunity to keep up to date with the latest knowledge, further training and contacts with colleagues. Barriers to teaching in the own medical practice were concerns about not being able to treat the same number of patients, a possible disruption of practice operations and lack of space. An analysis of the subgroups of GPs who were not yet teaching physicians indicated similar motives and barriers regarding training students in their practices, with a slightly lower overall motivation.

Conclusion

The results describe the facets of the motivation of Thuringian GPs to train students and can be helpful for the expansion of a sustainable network of training GP practices. It is essential to address motives, to counter difficulties with individual solutions and to create targeted incentives.

[Acquiring general practitioner roles during the outpatient postgraduate training section and profession-forming postgraduate training conditions in family physician practices - A survey among family medicine residents in Rhineland-Palatinate during their postgraduate training in general medicine]

BACKGROUND

Postgraduate training in general medicine should be oriented on competencies and profession-forming, as is suggested by the German Regulations on Specialist Training of federal and state governments and the Competence-based Curriculum General Medicine. The learnability of general practitioner (GP) roles and the profession-forming orientation of the postgraduate training conditions during the outpatient postgraduate training period were investigated.

METHODS

A cross-sectional study in questionnaire design was conducted from October until December 2019 among 220 physicians in postgraduate training who were registered at the Association of Statutory Health Insurance-Accredited Physicians in Rhineland-Palatinate for the specialty of general medicine. The GP roles surveyed were based on the "CanMEDS General Medicine" roles. Using indicators created from the didactic model "Cognitive Apprenticeship", profession-forming alignment of postgraduate training conditions in the GP practices were studied. The data obtained were analysed descriptively.

RESULTS

The response of 70 evaluable questionnaires included a gender distribution of 51 female and 18 male family medicine residents. The family medicine residents were almost equally divided between single-handed practices, cooperating practice associations and group practices. Slightly more than half of the female physicians worked part-time, whereas the male physicians were all full-time employees. The roles of "member of an interprofessional team", "health advocate" and "medical expert" were perceived as learnable by 70 to 90% of the family medicine residents. In addition to approval, varying degrees of indecision and rejection were expressed regarding the learnability of the roles of "teacher/scholar", "member of a network" and "employer". A slight majority considered the appropriation of the role of "practice manager" to be critical. Within the survey of profession-forming postgraduate training conditions, the indicators "accessible contact person", "collegial appreciation" and "assumption of responsibility" were approved by more than 90% in some cases. The indicators "access to GP acting" (approx. 86%) and "resilience" (approx. 71%) also received high approval ratings. However, the indicator "continuous feedback" only received a slight majority of approval.

DISCUSSION

GP postgraduate training practices in Rhineland-Palatinate apparently offer suitable educational locations to family medicine residents to acquire a solid basis for professional practising and the skills for patient-oriented communicating of preventive health-promoting contents. Male physicians seem to follow more traditional professional hierarchies. In contrast, female physicians are more receptive to teamwork but tend to be sceptical about adopting a leadership position. The learnability of particular GP roles may benefit from close collaboration with the practice owner, especially in single-handed practices. In addition, the working time model chosen seems to have an effect.

CONCLUSIONS

It can be assumed that profession-forming postgraduate training conditions predominate in Rhineland-Palatinate GP postgraduate training practices, where the role of "medical expert" also appeared to be learnable in most cases. The learnability of GP roles were influenced by the factors "gender", "working time model" and "form of practice" in some cases significantly. Consequently, it could have a quality-enhancing impact if these factors were taken into account in the development of measures to realize competence orientation in GP postgraduate training.

Predictors of patients' acceptance of video consultation in general practice during the coronavirus disease 2019 pandemic applying the unified theory of acceptance and use of technology model

Background

The coronavirus disease 2019 pandemic has led to an increase in remote consultations in health care. This study aimed to assess the acceptance of video consultation as an alternative to face-to-face in-office visits in general practice (GP) and to investigate its drivers and barriers.

Methods

A cross-sectional study was conducted in Germany during the coronavirus disease 2019 pandemic from December 2020 to April 2021. Participants were recruited among patients in 16 GP surgeries. Assessed were sociodemographic and medical data as well as information and communications technology related data. Acceptance of video consultation and its predictors were determined using a modified questionnaire based on a short version of the renowned unified theory of acceptance and use of technology model.

Results

In total, 371 participants were included in the data analysis. Acceptance of video consultation was moderate. A hierarchical regression revealed acceptance was significantly predicted by the PHQ-2, taking no regular medication, computer proficiency, knowledge about digital health care solutions, no prior use of video consultation, and the unified theory of acceptance and use of technology predictors performance expectancy, effort expectancy, and social influence. The extended unified theory of acceptance and use of technology model explained significantly more variance than the restricted unified theory of acceptance and use of technology model in acceptance of video consultation.

Conclusions

In this study computer proficiency, existing knowledge about digital health care solutions and depressive symptoms functioned as drivers to acceptance, no prior use of video consultation could be identified as a potential barrier. Patients with regular medication have been particularly receptive to video consultation. The study confirmed the validity of the unified theory of acceptance and use of technology model in determining acceptance of video consultation. Considering that there is growing demand and acceptance for different approaches to engage with health care providers, additional steps should be taken to establish video consultation as a genuine alternative.

Walking a mile in Grandma’s shoes - medical students’ evaluation of a very simple online aging game to enhance their understanding of older patients

Background

Aging simulation games are established educational interventions to make older patients’ perspectives noticeable, raise awareness about their needs, and positively influence attitudes toward older adults. Due to the COVID-19 pandemic restrictions imposed on education, we replaced a classroom-based aging simulation course with a simple online equivalent. This consisted of short introductory screencasts, four downloadable Portable Document Format (PDF) files containing issue-specific audio and video links, quizzes, case studies, and prompts for reflection. We explored how well our self-directed simple online simulation succeeded in providing students with relevant insights and experiences, raising awareness about age-related difficulties, and enhancing understanding of older patients.

Methods

In this cross-sectional study, an anonymous post hoc online survey was conducted among 277 5th-year medical students eligible for the course at the Leipzig University in May 2020. The questionnaire addressed overall course evaluations, assessments of the individual PDF components (working enjoyment, personal insights, professional learning gain, enhanced understanding, increased interest in working with older patients), and students’ main insights from the course (free text). Descriptive statistical and qualitative content analyses were performed.

Results

The response rate was 92.4% (n = 256, mean age 25.7 ± 3.4 years, 59.8% women). Nearly all respondents reported that the course was well structured, easily understandable, and that processing was intuitive. The majority (82.8%) perceived the course as practice-oriented, 88.3% enjoyed processing, 60.3% reported having gained new professional knowledge, and 75.4% had new personal insights. While only 14.8% agreed that the online course could generally replace the real-world simulation, 71.1% stated that it enabled them to change their perspective and 91.7% reported enhanced understanding of older patients. PDF components containing audio and video links directly imitating conditions (visual or hearing impairment) were rated highest. Qualitative data revealed manifold insights on the part of the students, most frequently referring to aspects of professional doctor-patient interaction, knowledge about conditions and diseases, role reversal, and enhanced empathy.

Conclusion

Simple online aging simulations may be suitable to provide students with relevant insights and enhance their understanding of older patients. Such simulations could be alternatively implemented in health professionals’ education where resources are limited.

The negative factors influencing the career intention of general practice trainees in eastern China: a qualitative study

BACKGROUND

There is an acute shortage of general practitioners (GPs) in China, and GP trainees seem to be less willing to develop their career as a GP. This study aimed to investigate negative factors influencing the career intention of GPs in eastern China from the perspective of trainees taking standardized residency training, as to identify the barriers of GP trainees becoming registered GPs, and to provide a policy-making basis for GP recruitment and retention.

METHODS

A qualitative description design by the purposive sample was carried out in two training bases of Jinan and Qingdao in eastern China. Face-to-face, in-depth, semi-structured interviews were conducted, audiotaped, and transcribed using thematic analysis.

RESULTS

Twenty-one trainees participated in this study. Thematic analysis generated five major themes: (1) low social recognition, (2) low professional identity, (3) low remuneration level, (4) imperfect training system, and (5) influence of policy factors.

CONCLUSIONS

Our results identified various negative factors influencing the career intentions of trainees. In order to overcome the hurdles and increase the attractiveness of GP, it is recommended that the government and the public should create a supportive environment, which can be beneficial to the construction and development of GP.

Workshop with medical students on physicians' earning opportunities, workload and job satisfaction increases the attractiveness of working self-employed and working in general practice

BACKGROUND

Among the various factors identified as relevant for primary care career choice, financial considerations have been consistently shown to have an impact. In Germany, reliable and easily understandable information on physicians' earning opportunities in self-employed settings is difficult to obtain for medical students, leading to substantial misperceptions that may negatively affect respective career considerations. This study investigated medical students' evaluation of a 45-min evidence-based workshop on earning opportunities, workload and job satisfaction in different specialties and settings to examine its effect on the perceived attractiveness of working self-employed and working in general practice.

METHODS

The workshop was implemented as part of a mandatory general practice clerkship in the fourth study year (of six). Post-hoc evaluations of all participants between October 2017 and September 2018 (one cohort) were analysed cross-sectionally including descriptive statistics, subgroup comparisons and qualitative analysis of free-text answers regarding students' main insights.

RESULTS

Response rate was 98.1% (307/313). Participants were on average 25.0 years old, and 68.3% were women. Based on a ten-point scale ranging from 1 = 'no influence' to 10 = 'very big influence', 91.9% confirmed at least some (> = 2) and 57.3% a rather high (> = 5) influence of earning expectations on their career choice process. Regarding the workshop, 86.1% were overall satisfied, and 89.5% indicated they had gained new insights, primarily regarding earning opportunities in different specialties and work settings, and frequently regarding job satisfaction, workload and the structure of revenues and expenditures in a doctor's office (according to qualitative analysis). In the opinion of 89.8% of students, the provided learning content should be part of the undergraduate curriculum. More than half of participants reported an increase regarding the attractiveness of working self-employed and working as a general practitioner, most frequently regarding earning opportunities, but also in general and in respect to job satisfaction, cost-benefit ratio and workload. This increase was significantly higher among students favouring or at least considering a general practice career.

CONCLUSIONS

The workshop and its content were appreciated by the students and showed clear potential to usefully complement undergraduate curricula aiming at increasing or reinforcing students' interest in working self-employed and working in general practice.

Facilitate Signing with the Family Doctor: A Study of the Practice in Shanghai, China

Background

In the time since primary care was implemented in China in 2009, programs of promoting residents signing with family doctor services have been key. However, there has been a lack of effective evaluation of its implementation.

Methods

We used mixed methods for evaluating existing measures of facilitating signing with family doctors in Shanghai. Based on the Donabedian model, qualitative informant interviews were conducted to obtain experts’ evaluations in aspects of team construction (structure) and innovative solutions for promoting and supervising signings (process). Quantitative data were used to analyse the utilization situation (outcome) from “Shanghai Family Doctor Signing Data Platform”.

Results

Measures of signing with family doctors in Shanghai have functioned well, but there is still a lack of sufficient family doctors and specialists, including paediatricians and gynaecologists. Although proportions of the key population (average=62.59%) and the elderly population (>65 years) (average=78.10%) who had signed with family doctors were relatively high, the proportion of the permanent resident population (average=29.36%) who had signed with family doctors was low from 2017 to 2020 in Shanghai. The proportions of residents seeking medical advice in signed community health centres in outskirts (71.08%) were higher than those in suburbs (63.51%) and urban areas (53.49%), whereas the proportion of those seeking medical advice from recommended multiple medical institutions were similarly low in urban areas, outskirts and suburbs.

Conclusion

The practice of facilitate signing with family doctors in Shanghai has increased. However, we showed that numbers of family doctors were relatively low, and there remains a need for more experienced gynaecology and paediatrics professionals, compared with Western countries. Additionally, efforts should be made to increase proportions of residents who utilize the program, especially in urban areas, and seek medical services in contracted group hospitals and community health centres.

[What is the contribution of physician assistants to health care in Germany? A differentiation between physician assistants and physicians in training]

BACKGROUND

Physicians in training are major contributors to the German health care system. After graduation from medical school, physicians in training qualify for a certain specialty. The workload of physicians in training in Germany is so high that they have expressed their need for support. One opportunity to support physicians in training is by delegating tasks to physician assistants (medical assistants qualified by a specific course of study, graduated from universities of applied sciences). However, there is a lack of knowledge about the qualification of physician assistants and the conditions which allow support of physicians in training by physician assistants in Germany.

METHODS

Based on a focused internet search, this paper describes the development of the profession physician assistance in Germany and the currently offered graduation courses including their duration and qualification requirements. Furthermore, we present available recommendations for the content of physician assistants' education and characterize conditions for the support of physicians in training by physician assistants.

RESULTS

In Germany, physician assistance has been an academic discipline since 2005, the profession is, however, still quite seldom. Qualification requirements and the duration of education are determined by the universities. The aim is to qualify students for several competencies, which enable physician assistants to perform tasks of physicians under delegation. The conditions for delegation to physicians in training and to physician assistants are quite similar, resulting in partly comparable practice. Major differences relate to the so called "physician reservation" or physicians' core area, both of which define tasks that may only be carried out by physicians.

DISCUSSION

Integrating physician assistants into a medical team means supporting the specialists by delegating tasks, thus reducing the workload of all physicians in the team, including physicians in training. Currently, there are no data on and no outcomes of the performance of physician assistants in Germany.

CONCLUSION

In everyday practice, health care delivered by physician assistants and by physicians in training is similar, at least as regards activities and tasks that do not need physician supervision.

[Care supply projections as a building block of evidence-based health services planning]

INTRODUCTION

As part of the measures to combat the shortage of general practitioners (GPs) particularly in rural areas, health services planning is becoming increasingly important.

METHODS

This paper shows how the quality of health services planning can be improved by combining population forecasts and physician number forecasts based on the cohort component method. On the basis of already available data (population data and doctors' registers), developments in the levels of care supply can be predicted on a small regional scale. The regional and temporal differentiation allows for early identification of specific needs for action. However, it is important to consider limitations in the interpretation of results.

RESULTS

The example of Lower Saxony shows that by 2035 a decline of more than 20% in the number of GPs is expected. At the same time, regions are affected to varying degrees, and even within the more vulnerable rural areas there are heterogeneous developments which require regionally adapted responses.

CONCLUSION

The greater the gap between supply and demand, the more important high-quality planning for efficient allocation of health services becomes. Against this background, care supply projections can serve as a useful building block of evidence-based care planning.