[Multimodal selection of medical students: The predictive power of individual process components in the two-stage selection process at Witten/Herdecke University (UW/H)]

OBJECTIVE

According to the legislator's ideas, the selection of medical students in Germany should no longer be based on the Abitur grade alone. This approach has already been implemented in the two-stage selection process at Witten/Herdecke University (UW/H) using several criteria. On the one hand, the present study aims to determine the prognostic value of the procedural components for the overall performance on the selection day. On the other hand, the different strategies of the applicants in processing the written task (phase 1) will be examined with regard to their application success.

METHODOLOGY

Data on applications for the summer semester 2020 (N = 819 phase 1; N = 233 phase 2) were available retrospectively. A stepwise regression analysis was conducted to determine the predictive power of each procedural component. Using a summary content analysis, the four essays from the applicants' motivation letters were structured and categories were identified, and an extreme group comparison (Group 1: Not invited; Group 2: University acceptance; N = 60 essays) was conducted.

RESULTS

As the stepwise regression analysis shows, the individual biographical interview emerged as the strongest predictor in terms of overall performance, followed by lecture, group interview, and multiple mini interviews. Content analysis extracted content and scaling categories for the individual essays, as well as an additional meta-category (Impression Management, IM). Successful applicants demonstrated, among other things, better judgment skills, more sophisticated reasoning skills, and an internalized role model as a physician. In addition, they used defensive IM strategies, e.g., subjectification and self-deprecation, more frequently.

CONCLUSION

Biographical interview is considered the strongest predictor of overall performance. The dimensions of impression management, reasoning quality and judgment proved to be reliable predictors of successful performance in the selection process. In addition, role image as a physician and professional commitment had a favorable effect on the selection decision.

[How important is an academic career in medicine today? A survey of medical students in Germany: results of study arm XIII of the KARiMED study]

OBJECTIVE

Academic careers still play a significant role in medicine. Although the doctorate remains interesting for many students, there are no data available from medical students, for example, with regard to the interest of a habilitation. In parallel, a good work-life/family balance is a key career element for young medical professionals. The aim was to obtain an up-to-date opinion on the academic career of medical students.

METHODOLOGY

Using an online survey, medical students of all semesters in Germany were questioned on the topics of academic career, mentoring, and work-life balance from October 2017 to December 2018. For this purpose, the medical students were invited by e-mail to participate and answer an anonymized online questionnaire.

RESULTS

A total of 1,775 participants from all 38 German medical faculties (68.3% female; age 23.3 ± 4.0 years) were included. Almost half of the participants could envision working in a branch office after graduation. While a professional career appeared important to a clear majority (70.8%), leisure time was rated as even more important (84.3%), and work-life balance clearly prioritized personal life (41.2%) over career (9.6%). Acquiring a title was rated as important to one's career by 53.6%. However, while the acquisition of a doctorate was still an option for 88.0% of the respondents, the situation is significantly different for academic titles following a successful habilitation. Although the significance of a habilitation is rated as high to very high (66.1%), the titles of assistant professor ("yes": 13.0%), associate professor (6.0%) or university professor (7.0%) are much less likely to be considered by medical students and are therefore rated as "maybe" and "no". Nevertheless, almost 60% wished for better information and advice in their future field of work.

CONCLUSION

Careers in medicine are undergoing a transformation where better compatibility of leisure/family and work is no longer the sole focus. On the contrary, work-life blending is sought, as a connection between work and life. Changes are therefore necessary for professional and especially academic careers in order to make working in science and research attractive again.

Bad things can happen: are medical students aware of patient centered care and safety?

Objectives

Quality and safety in healthcare are of the utmost importance, but little is known about whether undergraduate students are aware of patient safety concepts. The objectives of our study were to assess the perception of medical students of challenges in patient safety, and collect their perceptions of error management and prevention.

Methods

This study used an exploratory mixed method strategy. The first study phase collected data from semi-structured interviews of 28 students. Based on this, an online survey was constructed and sent to about 80,000 medical students in Germany. 1053 replies were received and analyzed for responses based on gender, curriculum type (problem based [PBC] vs. science based curriculum [SBC]) and years of training.

Results

Most students understand the importance of patient safety, error avoidance, and the challenges of patient safety interventions. Four themes were identified: (a) the culture of patient safety (what is a good doctor? Doctors’ responsibility), (b) the working environment (the inevitability of mistakes, high work load, hierarchy, competition, teamwork), (c) the challenges of risk reduction (error avoidance, management, skills), and (d) materialistic issue (income vs. humanistic values). Female students were more risk aware than male students. Sixteen percent of students expect negative effects (e.g. punishment) when medical errors were disclosed in a team. Regardless, >70% regard teamwork as an effective error avoidance measure. Error disclosure willingness was high (89.7%).

Conclusions

Although not formally part of the curriculum, students had a positive perspective concerning patient safety. The opportunities and challenges for incorporating patient safety content into the training curriculum were identified and presented.

Millennials Medical Students Generation at the Crosswalks: Motivations and Attitudes Towards Study and Future Career - A Mixed-Method Study

BACKGROUND AND OBJECTIVES

The aim of this study was to investigate in the millennium medical student generation the influence of the curriculum (problem-based curriculum [PBC] vs science-based curriculum [SBC]), gender and semester level on medical students' motives to study medicine, their attitudes toward their career and in this regard their view about their study condition in university.

METHODS

Semi-structured qualitative interviews with 28 medical students were performed and analyzed using Mayring's content analysis. Based on these results, a quantitative questionnaire for a nationwide survey was developed using a mixed-method-approach and send to most medical faculties in Germany. Data from n=1053 students entered statistical analysis.

RESULTS

Humanistic ideals prevailed in the choice to enter medical school and to become a physician. PBC students were found to be significantly (p<0.001) more idealistic and patient oriented, and they regard their curriculum more competitive than SBC-students (p<0.001). A balanced work and family life is essential for all students but particularly important for the PBC - group, male and undergraduate students. The majority of students wanted to work with patients and omitted patient-distant line of work. Undergraduate SBC-students saw their studies as old-fashioned citing lack of patient contact (p<0.001 compared to PBC), which eased in the graduate study part.

CONCLUSION

This study found major differences in student's perceptions depending on curriculum type. PBC-students were more idealistic, and humanistic ideals prevailed in comparison to SBC. For both, close patient contact is essential in their training. Particularly for female students, lifestyle factors and a balanced work-life-integration outweigh career ambitiousness. This study offers an important insight to policy makers and educators to understand the motivation and perceptions of the millennial student generation regarding their studies and future career plans, which should be considered in educational policies.

Mental Stress in Medical Students during the Pandemic and Their Relation to Digital and Hybrid Semester-Cross-Sectional Data from Three Recruitment Waves in Germany

BACKGROUND

Because of the COVID-19 pandemic, students had to interrupt their regular studies, and universities changed their teaching formats. The aim of this study was to analyze medical students' stress perception, wellbeing, life and work satisfaction, and cool down reactions, and to compare the survey data of online and hybrid semesters with pre-pandemic education formats in-person.

METHODS

Cross-sectional surveys at three time points enrolling 1061 medical students (58% women; 24.4 ± 3.4 years); 30.8% from pre-pandemic formats in-person, 22.8% from pandemic online semesters, and 46.1% from pandemic hybrid semesters.

RESULTS

Both students' stress perception and psychological wellbeing decreased during the pandemic semesters. Their satisfaction with the university support was at its lowest during the hybrid semesters. Regression analyses indicated that students' stress perception can be explained only to some extent by their general dissatisfaction with their medical studies or teaching formats.

CONCLUSIONS

The lockdowns affected students in more ways than simply their teaching formats. Students require individual support to adjust to difficult situations, and particularly medical students in their preclinical phase compared to students in their clinical phases. These are challenges for the medical education system, which must find ways to be prepared for future times of crisis and insecurity.

Germany-wide evaluation of residency in neurological intensive care medicine

BACKGROUND

Neurointensive medicine is an important subspecialization of neurology. Its growing importance can be attributed to factors such as demographic change and the establishment of new therapeutic options. Part of the neurological residency in Germany is a six-month rotation on an intensive care unit (ICU), which has not yet been evaluated nationwide. The aim of this study was to evaluate kind and feasibility of neurointensive care training in Germany and to discover particularly successful training concepts.

METHODS

In a preliminary study, ten residents and ten instructors were interviewed. Using content analysis, two questionnaires were created, which contained questions about specific teaching methods as well as individual satisfaction. The questionnaires were sent to 187 neurological clinics in Germany, and residents and instructors were asked to participate in the study. The data analysis was performed using SPSS and content analysis for the free-text data.

RESULTS

Seventy of the 187 clinics contacted did not offer ICU-rotation. At 59,8% (n = 70) of the remaining hospitals, a total of 154 participants (84 residents, 70 educators) could be recruited. General satisfaction with the neurointensive medical training is high in both groups (residents: 3.34 ± 0.54; instructors: 3.79 ± 0.41, evaluated on the basis of a Likert scale from 1 = "not satisfied" to 5 = "fully satisfied"). Specific teaching methods (e.g. simulation trainings, feedback sessions) are perceived as very useful by residents, but rarely take place. Instructors are interested in educational opportunities such as didactic courses.

CONCLUSION

This study provides an overview of the ICU-rotation as part of the five-year neurological residency. Neurointensive care rotations usually take place at maximum care hospitals and last at least seven months. Despite frequent time and personnel restrictions, motivation of trainers and residents is high. Nevertheless, teaching methods as simulation training and educational opportunities for instructors must be expanded.

The prognostic validity of the formative for the summative MEQ (Modified Essay Questions)

Objective: The purpose of formative examinations is that students and lecturers receive an early feedback regarding the success of learning behavior and teaching methods. These also serve as practice for later summative exams. The aim of this paper is to investigate to what extent the result of the formative MEQ* at the end of the first semester at Witten/Herdecke University (UW/H) in the study program human medicine can be used as a predictor for the summative MEQ-1 at the end of the second semester which is part of the equivalence examination replacing the state examination. Methodology: The predictive value of the score achieved in the MEQ* on the MEQ-1 score, as well as the potential influence of the variables gender, age, high school graduation grade (German Abiturnote), professional background, and self-efficacy expectancy, was determined for students of human medicine. Results: Data from two cohorts of UW/H with a total of 88 students were included. Scores on the formative MEQ* correlate with those on the summative MEQ-1 in both cohorts. In regression analyses, only the score on the MEQ* proves to be a significant predictor of performance on the MEQ-1 (40.5% variance explanation). Particularly significant predictors are the scores in the subjects anatomy and clinical reasoning. Vocational training or pre-study only appear to contribute to higher scores in the MEQ* after the first semester, but have no further significance in predicting scores in the MEQ-1. Conclusion: The MEQ* was confirmed to be a good predictor of the MEQ-1. Thus, it serves as a formative exam to inform students about their current state of knowledge with regard to the summative exam MEQ-1, so that they can adequately adapt their learning strategies in the course of the second semester.

[Child and Career, but When? Mixed Methods Research on Starting a Family During Student Years vs. after Graduation from Medical School]

BACKGROUND

More and more women are studying medicine these days. They often face a conflict between having children and pursuing a career. Thus, a challenging question arises for a new generation of young doctors: How can children and career be reconciled? Also, the right time to start a family plays an important role. At the University Witten/Herdecke, students with and without children were asked to what extent their time when they were students of medicine proved to be a convenient time to start a family.

METHODS

A questionnaire survey was carried out in which a total of 423 medical students took part. A further 12 medical students with children were also interviewed about their situation using a guided interview. Results were evaluated using a qualitative content analysis.

RESULTS

Medical students with children saw that there were advantages in terms of family and career to starting a family during their studies, but noted the disadvantages in terms of studies and the financial situation. The majority of medical students without children were undecided about the ideal time to start a family, but only 18% considered the student years to be the ideal time for this. Among medical students with children, on the other hand, 50% considered the student years as the ideal time to start a family and only five percent perceived the time after their studies as ideal.

CONCLUSION

In order to facilitate combining children and career across the entire career path as a medical doctor, political and university policy concepts should be developed that take into consideration financial relief and flexible study organization.

Selection procedure human medicine and psychology at the University of Witten/Herdecke: adaptation to the virtual zoom room

Introduction: For the selection of students for the winter semester 2020/21, the established selection procedure of the University of Witten/Herdecke (UW/H) was adapted to the virtual space in view of the current contact ban and recommended keeping of distance. The three stations in the second step of the procedure, the biographical one-on-one interview, presentation and discussion on a subject-specific topic as well as multiple mini interviews (MMI) on the social skills of the applicants were audiovisual and in real time in zoom meetings. Project description: The medical, psychological and student reviewers were prepared for the virtual selection procedure in training sessions. Three weeks before the selection days, the applicants received information on the technical requirements for the interviews and on data protection for the persons affected by the collection of personal data. The evaluation of the virtual selection procedure was carried out by the reviewers using an online questionnaire with 8 socio-demographic, 5 organizational, 8 content and 3 open questions. Results: The 108 reviewers conducted selection interviews in tandems (medical/psychological and student reviewers) with 178 applicants for human medicine and 105 applicants for psychology. The online evaluation by 58 reviewers (response rate 53.7%) showed a positive agreement with the virtual selection procedure, with a more favorable assessment of organization and content by the medical and psychological reviewers compared to the student reviewers. Discussion: The adequate adaptation of the selection procedure of the UW/H to the virtual zoom room as well as its acceptance are confirmed by the successful execution of the selection days for the students for the winter semester 2020/21 and the evaluation of the reviewers. Conclusion: The results and analysis of this exceptional situation will be used to also conduct the upcoming selection procedure for the summer semester 2021 in the virtual space. A valid assessment for the future use of a virtual selection procedure as a possible supplement to the personal selection interviews at the University of Witten/Herdecke remains to be made.

Spontaneously retrievable knowledge of German general practitioners depending on time since graduation, measured with the progress test medicine

Background: General practitioners and general internists occupy a key position in German and Austrian healthcare systems. They provide primary care and act as gatekeepers between medical disciplines and sectors of care. Their explicit medical knowledge levels, however, can be quite disparate. Objective: This study analyses whether general practitioners' performances on a standardised knowledge test changes with four relevant socio-demographic variables. Design: The survey was based on the Progress Test Medicine (PTM), a standardised 200 item knowledge test on graduate level. After formal blueprinting and item analysis, 60 items of PTM were selected ("PTM-GP") for our study. Participants: PTM-GP was presented ad hoc to general practitioners and internists from Germany and Austria at a number of professional meetings in 2011. 161 volunteers completed the survey. Main measures: For evaluation, correlation analysis (Spearman), Kruskal Wallis-tests for non-parametric data and an analysis of covariance (ANCOVA) were calculated. Results: Overall, four indicators turned out to be slightly significant for the performance on the PTM-GP, namely: time passed since graduation, the grade received in the licensing examination, the type of institution for postgraduate training, and the medical specialisation. Conclusions: Recent graduates performed better in the PTM-GP; a doctor's licensing examination grade as well as training at a university hospital correlated positively with PTM-GP performance. A general doctor's knowledge level is moderately influenced by exam grades, time since graduation, the institutional affiliation of postgraduate training and medical specialisation. Individual changes in knowledge over time have to be deliberately considered in lifelong learning. In consequence, the on-going teaching of medical knowledge should be integrated mandatory and verifiable into general doctors' everyday practices, e.g. through repetitive knowledge tests with individual feedback and recommendations for further continuing medical education (CME).

Education Research in German Non-Medical Health Care Professions compared to International Developments: a Bibliometric and Content-Related Publication Analysis

This article was migrated. The article was not marked as recommended. Background: In Germany academic degree programs for non-medical health care professions (nursing, physical, occupational and speech language therapy, midwifery) have been established only recently, even if they play a key role in today´s complex patient-centered health care. The aim of this study was to evaluate the development and current state of German education research in these professions as well as to conduct a comparison to international research activities in this field. Method: To achieve these objectives a bibliometric and content-related publication analysis was performed from 2008 to 2017 in four international high-impact journals. Based on appropriate inclusion criteria (bibliographical and biographical criteria, focus on first and last author, original study) and their development into a coding scheme, articles were recorded systematically and results analyzed quantitatively and content-wise. Group comparisons between German and international health care professions as well as interdisciplinary comparisons between the individual professions were performed. Results: On the whole, 11.891 articles were analyzed for participation of the respective target groups, either as first or as last author. Of these, 164 original studies met the inclusion criteria with 157 publications pertaining to international and only seven to German health care professionals. The majority of authors belonged to the discipline of nursing science (n=138). North America (36.63%), Australia (18.32%) and Asia (14.85%) rank among the regions that publish most frequently. Publications by German health care professionals are rare but showed an overall high level of quality. Conclusion: International publication activities by non-medical health care professionals have been on the rise in recent years. Specific funding measures as well as transnational and interdisciplinary collaborations may be potential ways of strengthening and expanding education research in countries with only young academic experiences.

Comparison of the evaluation of formative assessment at two medical faculties with different conditions of undergraduate training, assessment and feedback

Introduction: Both formative and summative assessments have their place in medical curricula: formative assessment to accompany the learning process and summative assessment to ensure that minimum standards are achieved. Depending on the conditions of undergraduate training, assessment and feedback, students place more or less importance on formative assessment, and thus the fulfilment of its function may be questionable. This study describes how the low-stakes formative Berlin Progress Test (BPT) is embedded at two medical faculties with partially different framework conditions and what effects these have on the students' testing efforts and the evaluation of the test, especially the perception of its benefits and (intangible) costs, such as non-participation in contemporaneous activities and emotional impairments. Methods: In this study, the proportion of non-serious BPT participants at two medical faculties (total sample: N_F1=1,410, N_F2=1,176) in winter term 2015/16 was determined both by the number of unanswered questions on the test itself and in a survey using a standardized instrument (N_F1=415, N_F2=234). Furthermore, open questions were asked in this survey about perceived benefits and perceived costs, which were analyzed with qualitative and quantitative methods. Results: The BPT is generally better accepted at Faculty 2. This can be seen in the higher proportion of serious test takers, the lower perceived costs and the higher reported benefit, as well as the higher proportion of constructive comments. Faculty 2 students better understood the principle of formative testing and used the results of the BPT as feedback on their own knowledge progress, motivation to learn and reduction of exam fear. Discussion: When medical faculties integrate formative assessments into the curriculum, they have to provide a framework in which these assessments are perceived as an important part of the curriculum. Otherwise, it is questionable whether they can fulfil their function of accompanying the learning process.

Institutional strategies related to test-taking behavior in low stakes assessment

Low stakes assessment without grading the performance of students in educational systems has received increasing attention in recent years. It is used in formative assessments to guide the learning process as well as in large-scales assessments to monitor educational programs. Yet, such assessments suffer from high variation in students' test-taking effort. We aimed to identify institutional strategies related to serious test-taking behavior in low stakes assessment to provide medical schools with practical recommendations on how test-taking effort might be increased. First, we identified strategies that were already used by medical schools to increase the serious test-taking behavior on the low stakes Berlin Progress Test (BPT). Strategies which could be assigned to self-determination theory of Ryan and Deci were chosen for analysis. We conducted the study at nine medical schools in Germany and Austria with a total of 108,140 observations in an established low stakes assessment. A generalized linear-mixed effects model was used to assess the association between institutional strategies and the odds that students will take the BPT seriously. Overall, two institutional strategies were found to be positively related to more serious test-taking behavior: discussing low test performance with the mentor and consequences for not participating. Giving choice was negatively related to more serious test-taking behavior. At medical schools that presented the BPT as evaluation, this effect was larger in comparison to medical schools that presented the BPT as assessment.

Media Use Among Students From Different Health Curricula: Survey Study

BACKGROUND

Mobile devices such as smartphones, tablets, and laptop computers enable users to search for information and communicate with others at any place and any time. Such devices are increasingly being used at universities for teaching and learning. The use of mobile devices by students depends, among others, on the individual media literacy level and the curricular framework.

OBJECTIVE

The objective of this study was to explore whether there were differences in media use in students from various curricula at the Faculty of Health, Witten/Herdecke University.

METHODS

During the 2015-16 winter term, a survey was conducted at the Faculty of Health, Witten/Herdecke University, in which a total of 705 students (out of 1091 students; response rate: 705/1091, 64.61%) from 4 schools participated voluntarily: medicine (346/598), dentistry (171/204), psychology (142/243), and nursing science (46/46). The questionnaire developed for the study included 132 questions on 4 topics: (1) electronic and mobile devices (19 questions), (2) communication and organization of learning (45 questions), (3) apps/programs/websites/media (34 questions), and (4) media literacy (34 questions). The questionnaire was distributed and anonymously completed during in-class courses.

RESULTS

Students from all 4 schools had at least two electronic devices, with smartphones (97.4%, 687/705) and laptops (94.8%, 669/705) being the most common ones. Students agreed that electronic devices enabled them to effectively structure the learning process (mean 3.16, SD 0.62) and shared the opinion that university teaching should include imparting media literacy (mean 2.84, SD 0.84). Electronic device ownership was the highest among medical students (mean 2.68, SD 0.86) and medical students were the only ones to use a tutorial (36.1%, 125/346). Dental students most widely used text messages (mean 3.41, SD 0.49) and social media (mean 2.57, SD 1.10) to organize learning. Psychology students considered mobile devices to be most ineffective (mean 2.81, SD 0.83). Nursing science students used emails (mean 3.47, SD 0.73) and desktop computers (39%, 18/46) most widely.

CONCLUSIONS

The results show that almost all students use electronic learning (e-learning) tools. At the same time, different profiles for different degree programs become apparent, which are to be attributed to not only the varying curricula and courses but also to the life circumstances of different age groups. Universities should, therefore, pay attention to the diverse user patterns and media literacy levels of students when planning courses to enable successful use of e-learning methods.

Qualitative Studies on Implicit Criteria during the Individualized Selection Procedure for Medical Studies at Witten/Herdecke University (UW/H)

Objective: The individualized two-stage selection procedure for medical studies at Witten/Herdecke University (UW/H) has been in use for more than 30 years and comprises explicit and implicit selection criteria. This analysis aims at identifying the implicit criteria and answering the question whether an internal consistency of these implicit criteria may be verified for the different phases of the selection procedure (when evaluating the statements of purpose, during the selection weekend and during the concluding discussions of assessors). Methodology: Three qualitative studies on all phases of the selection procedure at UW/H have been conducted for determining the implicit assessment criteria of assessors: statements of purpose in extreme group comparison (12 admissions versus 18 rejections); semi-structured expert interviews (N=25) on the selection weekend; focus group analysis of the concluding discussions on two selection weekends (N=16). Results: The content analysis of the statements of purpose yielded 14 main categories with significant deviations between extreme groups in the categories school career, reasons for application and reflections as well as regarding the higher education entrance qualification grade. Based on the expert interviews, three main categories could be identified: intellectual ability, motivation and social competence, and the ability to reflect as a cross-content category. The focus group analysis yielded four main categories: performance, personality, personal growth potential and ability to reflect. Most frequently, the ability to reflect was mentioned as an assessment criterion. Conclusion: The main assessment categories are: motivation for the medical profession and starting studies at UW/H; performance and scholastic aptitude; personality, personal growth potential and social competence, as well as the ability to reflect as the most important basic competence and general category. Assessors consider the ability to reflect as a predictor of lifelong professional development as a physician.

Enhancing medical students' reflectivity in mentoring groups for professional development - a qualitative analysis

BACKGROUND

Professional competence is important in delivering high quality patient care, and it can be enhanced by reflection and reflective discourse e.g. in mentoring groups. However, students are often reluctant though to engage in this discourse. A group mentoring program involving all preclinical students as well as faculty members and co-mentoring clinical students was initiated at Witten-Herdecke University. This study explores both the attitudes of those students towards such a program and factors that might hinder or enhance how students engage in reflective discourse.

METHODS

A qualitative design was applied using semi-structured focus group interviews with preclinical students and semi-structured individual interviews with mentors and co-mentors. The interview data were analyzed using thematic content analysis.

RESULTS

Students' attitudes towards reflective discourse on professional challenges were diverse. Some students valued the new program and named positive outcomes regarding several features of professional development. Enriching experiences were described. Others expressed aversive attitudes. Three reasons for these were given: unclear goals and benefits, interpersonal problems within the groups hindering development and intrapersonal issues such as insecurity and traditional views of medical education. Participants mentioned several program setup factors that could enhance how students engage in such groups: explaining the program thoroughly, setting expectations and integrating the reflective discourse in a meaningful way into the curriculum, obliging participation without coercion, developing a sense of security, trust and interest in each other within the groups, randomizing group composition and facilitating group moderators as positive peer and faculty role models and as learning group members.

CONCLUSIONS

A well-designed and empathetic setup of group mentoring programs can help raise openness towards engaging in meaningful reflective discourse. Reflection on and communication of professional challenges can, in turn, improve professional development, which is essential for high quality patient care.

Development and validation of a computer-based situational judgement test to assess medical students' communication skills in the field of shared decision making

OBJECTIVE

To develop a computer-based test (CBT) measuring medical students' communication skills in the field of shared decision making (SDM) and to evaluate its construct validity.

METHODS

The CBT was developed in the context of an experimental study comparing three different trainings for SDM (including e-learning and/or role-play) and a control group. Assessment included a CBT (Part A: seven context-poor questions, Part B: 15 context-rich questions) and interviews with two simulated patients (SP-assessment). Cronbach's α was used to test the internal consistency. Correlations between CBT and SP-assessment were used to further evaluate construct validity of the CBT.

RESULTS

Seventy-two students took part in the study. Mean value for the CBT score was 72% of the total score. Cronbach's α was 0.582. After eliminating three items, Cronbach's α increased to 0.625. Correlations between the CBT and SP-assessment were low to moderate. The control group scored significantly lower than the training settings (p<0.001).

CONCLUSION

The CBT was reliable enough to test for group differences. For summative assessment purposes, considerably more questions would be needed.

PRACTICE IMPLICATIONS

We encourage teachers who particularly work with large student numbers to consider CBT as a feasible assessment method for cognitive aspects of communication skills.

The Questionnaire D-RECT German: Adaptation and testtheoretical properties of an instrument for evaluation of the learning climate in medical specialist training

AIM

Boor et al developed and validated the questionnaire D-RECT (Dutch Residency Educational Climate Test ) to measure the clinical learning environment within the medical specialist training. In this study, a German version of this questionnaire (D-RECT German) is analyzed regarding testtheoretical properties.

PROBLEM

Are the results of Boor et al replicable as a proof for validity of the questionnaire D-RECT?

MATERIAL & METHODS

The study was performed as online survey using the questionnaire D-RECT German (50 items in 11 subscales). To determine item characteristics and internal consistency (Cronbach's α), item- and reliability analyses were performed. Furthermore, a confirmatory factor analysis was performed using a model for maximum-likelihood estimation to evaluate validity.

RESULTS

This replication study on the psychometric properties of the D-RECT with 255 residents at 17 German hospitals revealed heterogeneous discriminatory power for all items and an internal consistency of Cronbach's α between 0.57 and 0.85. Within the confirmatory factor analysis, 6 items showed standardized regression coeffizients <0.5, two of them in the subscale "Attendings role". Furthermore, strong interdependencies (>0.7) were found between the subscales "Supervision", "Coaching" and "Attendings role".

CONCLUSION

The present replication study with the D-RECT German showed structural differences with respect to factorial validity underpinning the need of further validation studies.

What motivates young physicians? - a qualitative analysis of the learning climate in specialist medical training

BACKGROUND

Not least the much-invoked shortage of physicians in the current and the next generation has resulted in a wide range of efforts to improve postgraduate medical training. This is also in the focus of the current healthcare policy debate. Furthermore, quality and scope of available postgraduate training are important locational advantages in the competition for medical doctors. This study investigates the preferences and concerns that German house officers (HOs) have about their current postgraduate training. It also highlights how HOs evaluate the quality of their current postgraduate training and the learning environment.

METHODS

HOs were asked to answer the question: "Which things are of capital importance to you personally in your medical training?", using a free text format. The survey was conducted web based (Lime survey) and all data was anonymized. Summarizing qualitative analyses were performed using the software tool MaxQDA.

RESULTS

A total of 255 HOs participated in this study (female: n = 129/50.6 %; male: n = 126/49.4 %; age: 32 + 6 years) associated with 17 different German hospitals and from four medical specialties. Ten categories were generated from a total of 366 free text answers: 1. methodology of learning (n = 66), 2. supervision (n = 66), 3. learning structure (n = 61), 4. teaching competence (n = 37), 5. dedication (n = 34), 6. work climate (n = 29), 7. feedback/communication (n = 22), 8. challenge/patient safety (n = 21), 9. time/resources (n = 17), 10. personal security/safety (n = 13).

CONCLUSIONS

HOs want a reliable and curriculum-guided learning structure. Different studying techniques should be used with sufficient (time) resources available in a trusting and communicative learning environment. Competent and dedicated instructors are expected to give individual and specific feedback to the HOs on individual strengths and deficits. Instructors should develop educational concepts in cooperation with the HOs and at the same time avoid excessive demands on HOs or hazards to patients.

[Nationwide evaluation of German university teaching methods in neurology]

BACKGROUND

Germany is confronted with a lack of medical doctors and an increasing need for neurologists in particular. In order to recruit future doctors in neurology it is essential to attract young students when still at university.

OBJECTIVES

This article presents the first German national survey of medical students' acceptance of teaching methods in neurology. The participants evaluated teaching methods and examination formats and were asked about their preferences.

MATERIAL AND METHODS

The survey was based on a questionnaire distributed to 22 German medical schools and 1245 participating students.

RESULTS

Interactive teaching methods, especially courses in practical examinations, clinical internships and bedside teaching were highly rated among the students. In contrast, multiple choice tests, as one of the most widespread examination methods, were poorly rated compared to practical and oral examinations. For most of the students it was not decisive, in which semester teaching of neurology took place, while the majority asked for additional and more intensive neurological education.

CONCLUSION

The data give an overview of teaching of neurology in Germany and students' assessment of various approaches. The results should be utilized towards reorientation of future curricula that should aim at innovative and even more practically oriented teaching.

May student examiners be reasonable substitute examiners for faculty in an undergraduate OSCE on medical emergencies?

OBJECTIVES

To compare the effect of student examiners (SE) to that of faculty examiners (FE) on examinee performance in an OSCE as well as on post-assessment evaluation in the area of emergency medicine management.

METHODS

An OSCE test-format (seven stations: Advanced Cardiac Life Support (ACLS), Basic Life Support (BLS), Trauma-Management (TM), Pediatric-Emergencies (PE), Acute-Coronary-Syndrome (ACS), Airway-Management (AM), and Obstetrical-Emergencies (OE)) was administered to 207 medical students in their third year of training after they had received didactics in emergency medicine management. Participants were randomly assigned to one of the two simultaneously run tracks: either with SE (n = 110) or with FE (n = 98). Students were asked to rate each OSCE station and to provide their overall OSCE perception by means of a standardized questionnaire. The independent samples t-test was used and effect sizes were calculated (Cohens d).

RESULTS

Students achieved significantly higher scores for the OSCE stations "TM", "AM", and "OE" as well as "overall OSCE score" in the SE track, whereas the station score for "PE" was significantly higher for students in the FE track. Mostly small effect sizes were reported. In the post-assessment evaluation portion of the study, students gave significant higher ratings for the ACS station and "overall OSCE evaluation" in the FE track; also with small effect sizes.

CONCLUSION

It seems quite admissible and justified to encourage medical students to officiate as examiners in undergraduate emergency medicine OSCE formative testing, but not necessarily in summative assessment evaluations.

Use of elaborate feedback and an audience-response-system in dental education

Introduction: The aim of the study was to examine the effect of an elaborate feedback and an audience response system (ARS) on learning success.

Methods: Students of the 1^st clinical semester were randomly assigned to a study and a control group. The randomization was carried out considering the factors of age, gender and power spectrum during preliminary dental examination. Within 10 lectures 5 multiple-choice questions were asked about the learning objectives and answered by the students using an ARS. Only the study group received an immediate comprehensive feedback on the results. A final exam at the end was carried out in order to evaluate whether the elaborate feedback leads to a successful learning. Furthermore the effect of the ARS on the lecture atmosphere was investigated.

Result: The results of the final exams showed no significant difference between the study and the control group regarding the learning success.

Conclusion: Although no significant effect on learning success was found, the ARS creates a more interactive, positive learning environment.

Using an audience response system to improve learning success in practical skills training courses in dental studies - a randomised, controlled cross-over study

INTRODUCTION

The aim of this study was to examine whether the use of an audience response system (ARS) in a high-quality study design, in a course in pre-clinical dentistry leads to an improvement in cognitive and psycho-motor performance.

MATERIALS AND METHODS

As part of the Phantom Course I, a randomised, controlled study in cross-over design with 63 students was conducted over 4 weeks. The intervention was carried out by means of an ARS (TurningPoint(®) ), while a verbal question-and-answer session was conducted within the control group. Differences in learning success were determined via a formative multiple-choice (MC) test (cognitive) and a summative practical test (psycho-motor).

RESULTS

Both groups achieved significantly better results in the MC tests with the use of the intervention, when compared with the control group (group A 11.6 vs. 9.5 and group B 13.7 vs. 12.1, maximum 16 points). A further analysis of the results showed that the overall effect was induced primarily by a marked improvement in below-average students. The practical tests showed no clear effect. Despite the careful selection and set-up of the conditions for the study in the regular course of the semester, a cohort effect emerged. This was due to varying degrees of performance between the two groups, because no adequate performance parameters were available, which could have been taken into account for the stratified randomisation.

CONCLUSIONS

The results indicate that the use of the ARS leads to better results in cognitive performance, especially where independent learning is required and should be encouraged. Weaker students in particular seem to benefit.

[University teaching in clinical neurology: present situation and future requirements]

BACKGROUND

In German Hospitals there is a lack of medical personnel and doctors in particular. Clinical specialities and hospitals are in competition for students and young doctors and these, in turn, have clear cut demands regarding working conditions and professional training. To date there is considerable heterogeneity regarding clinical teaching in neurology between different German universities. There are no data available for systematic comparison.

MATERIAL AND METHODS

This article presents for the first time data from a survey on academic teaching in neurology in German university hospitals.

RESULTS AND CONCLUSION

The data show that many faculties are dedicated to modern and practical teaching methods and have employed state of the art examinations and progress tests. Further and ongoing efforts will be needed in order to inspire medical students and young doctors for this interesting clinical speciality. Connecting individual formats and networking between universities, teaching hospitals, including novel developments together with the young neurologists will help to structure our efforts and increase sustained attractiveness of clinical neurology for the following generations of young doctors.

Students benefit from developing their own emergency medicine OSCE stations: a comparative study using the matched-pair method

BACKGROUND

Students can improve the learning process by developing their own multiple choice questions. If a similar effect occurred when creating OSCE (objective structured clinical examination) stations by themselves it could be beneficial to involve them in the development of OSCE stations. This study investigates the effect of students developing emergency medicine OSCE stations on their test performance.

METHOD

In the 2011/12 winter semester, an emergency medicine OSCE was held for the first time at the Faculty of Medicine at the University of Leipzig. When preparing for the OSCE, 13 students (the intervention group) developed and tested emergency medicine examination stations as a learning experience. Their subsequent OSCE performance was compared to that of 13 other students (the control group), who were parallelized in terms of age, gender, semester and level of previous knowledge using the matched-pair method. In addition, both groups were compared to 20 students who tested the OSCE prior to regular emergency medicine training (test OSCE group).

RESULTS

There were no differences between the three groups regarding age (24.3 ± 2.6; 24.2 ± 3.4 and 24 ± 2.3 years) or previous knowledge (29.3 ± 3.4; 29.3 ± 3.2 and 28.9 ± 4.7 points in the multiple choice [MC] exam in emergency medicine). Merely the gender distribution differed (8 female and 5 male students in the intervention and control group vs. 3 males and 17 females in the test OSCE group).In the exam OSCE, participants in the intervention group scored 233.4 ± 6.3 points (mean ± SD) compared to 223.8 ± 9.2 points (p < 0.01) in the control group. Cohen's effect size was d = 1.24. The students of the test OSCE group scored 223.2 ± 13.4 points.

CONCLUSIONS

Students who actively develop OSCE stations when preparing for an emergency medicine OSCE achieve better exam results.

The aimed or feared professional future of medical students at the Univesity of Witten/Herdecke

The current challenges of educational policy seem to be associated to changes of the health care system, to counteract concerns regarding the lack of physicians, supply shortage and migration of specialists. Therefore, expectations, wishes and concerns relevant to the anticipated everyday life as a physician of medical students at the Witten/Herdecke University (UWH) were acquired with an online questionnaire. Useful for a direct comparison the results of the online survey ‘Medical Study and Future’ throughout Germany have been used. Findings from this survey are common characteristics regarding the choice of the profession and planning of an establishment as a general practitioner and clear differences in reflecting on future issues in the occupational field.

The Questionnaire "SFDP26-German": a reliable tool for evaluation of clinical teaching?

Aims: Evaluation of the effectiveness of clinical teaching is an important contribution for the quality control of medical teaching. This should be evaluated using a reliable instrument in order to be able to both gauge the status quo and the effects of instruction. In the Stanford Faculty Development Program (SFDP), seven categories have proven to be appropriate:

Establishing the Learning Climate,

Controlling a Teaching Session,

Communication of Goals,

Encouraging Understanding and Retention,

Evaluation,

Feedback and

Self-directed Learning.

Since 1998, the SFDP26 questionnaire has established itself as an evaluation tool in English speaking countries. To date there is no equivalent German-language questionnaire available which evaluates the overall effectiveness of teaching.

Question:

Development and theoretical testing of a German-language version of SFDP26 (SFDP26-German),

Check the correlation of subscale of SFDPGerman against overall effectiveness of teaching.

Methods: 19 anaesthetists (7 female, 12 male) from the University of Lübeck were evaluated at the end of a teaching seminar on emergency medical care using SFDP-German. The sample consisted of 173 medical students (119 female (68.8%) and 54 male (31.2%), mostly from the fifth semester (6.6%) and sixth semester (80.3%). The mean age of the students was 23±3 years.

Results: The discriminatory power of all items ranged between good and excellent (r_it=0.48-0.75). All subscales displayed good internal consistency (α=0.69-0.92) and significant positive inter-scale correlations (r=0.40-0.70). The subscales and “overall effectiveness of teaching” showed significant correlation, with the highest correlation for the subscale “communication of goals (p< 0.001; r = 0.61).

Conclusion: The analysis of SFDP26-German confirms high internal consistency. Future research should investigate the effectiveness of the individual categories on the overall effectiveness of teaching and validate according to external criteria.

Changes of neurobehavioral and sensory functions due to toluene exposure below 50ppm?

Data of a follow up study with four examinations were summarized by odds ratio statistics in order to scrutinize the results of the earlier studies with cross sectional approaches. For a "high"- (n=106) and a "low"-exposed group (references, n=86) current toluene exposures of 26ppm versus 3ppm and lifetime weighted average exposures of 45ppm versus 9ppm were ascertained. As measures of sensory functions vibration thresholds, colour discrimination, and auditory thresholds were used. Measures of psychological performances were attention (symbol-digit substitution, switching attention, simple reaction), memory (digit span forward, delayed reproduction of pictures), and psychomotor functions (steadiness, line tracing, aiming, tapping, peg board). Additionally, the frequency of diseases and symptoms were ascertained. By odds ratio statistics including relevant cofactors no significant increase of "cases with impaired functions" among the high-exposed workers was found. Evidence for neurobehavioral effects due to long-term toluene exposure below 50ppm was not established.

Colour vision and occupational toluene exposure: results of repeated examinations

Potential effects of human occupational exposures to toluene on colour vision were investigated in a follow-up study over 4 years with three repeated examinations. Colour vision was measured with the Lanthony desaturated colour vision test D-15d, and the colour confusion index (CCI) was calculated. The mean current exposures were 26+/-21 ppm for printers (high toluene level) and 3+/-4 ppm for end-processors (low toluene level). The mean exposure durations were 23+/-6 years for "long-time exposed" and 7+/-2 years for "short-time exposed" subjects. Repeated analyses (n=162) and multiple regressions (maximum available n=267) did not reveal significant effects of toluene with respect to intensity or duration of current or long-term exposure. Age and occupational qualification were significantly associated with CCI in both kinds of analysis, whereas alcohol consumption (carbohydrate-deficient transferrin, CDT) and smoking habits (cigarettes per day) were not. It is concluded that current industrial exposure limits of toluene provide sufficient protection against possible disturbance of colour vision.

Toluene exposure below 50 ppm and cognitive function: a follow-up study with four repeated measurements in rotogravure printing plants

OBJECTIVE

There are findings of cross-sectional studies on slight cognitive effects due to toluene exposure below 50 ppm. The critical points of the earlier studies will be scrutinised by a follow-up study with four examinations in 5 years.

METHODS

Employees from 14 magazine rotary printing plants were classified into groups of "high" (printing area) vs "low" (end-processing) and "short" vs "long" exposure. The sample size of 333 in examination 1 decreased to 216 in examination 4. A repeated-measurement design could be applied for 192 persons. Current exposure was measured by personal air sampling (n=2,521). Data for past exposure (lifetime weighted average exposure, LWAE) were based on job exposure matrices. High-exposure and low-exposure groups were characterised by 26 ppm vs 3 ppm (current exposure) and 45 ppm vs 9 ppm (LWAE). For long-exposure and short-exposure groups 21 vs 6 years were ascertained. Attention (symbol digit substitution, switching attention, simple reaction), memory (digit span forward and backwards, immediate and delayed reproduction of pictures), and psychomotor functions (steadiness, line tracing, aiming, tapping, peg board) were measured as dependent variables.

RESULTS

Separate stepwise regressions for examinations 1 to 4, which included the co-variables age, level of education, carbohydrate-deficient transferrin as an alcohol marker, and trait anxiety as personality characteristic, did not exhibit remarkable exposure impacts on the performance variables. Repeated-measures analyses of covariance, which included all examination periods, also did not exhibit significant impacts of LWAE or current exposure on the functions measured. Age and education were the dominant factors for the variability of the data. Additionally, carbohydrate-deficient transferrin and trait anxiety showed sporadic impacts on the test results.

CONCLUSION

Evidence for psychological performance effects due to long-term toluene exposure below 50 ppm could not be proved.

Occupational toluene exposure and auditory function: results from a follow-up study

The ototoxicity of occupational exposure to toluene below 50 p.p.m. was investigated in a longitudinal study over 5 yr with four repeated examinations starting with 333 male workers from rotogravure printing plants. Past lifetime weighted average exposures (LWAE) to toluene and noise were determined from individual work histories; recent individual exposures were measured 10 times during the study (toluene, active sampling; noise, stationary measurements). The auditory thresholds were measured with pure tone audiometry. The mean LWAE exposures to toluene and noise were 45 +/- 17 p.p.m. plus 82 +/- 7 dB(A) for printers (high toluene intensity) and 10 +/- 7 p.p.m. plus 82 +/- 4 dB(A) for end-processors (low toluene intensity). The mean current exposures to toluene and noise during the study were 26 +/- 20 p.p.m. plus 81 +/- 4 dB(A) for printers and 3 +/- 3 p.p.m. plus 82 +/- 4 dB(A) for end-processors. Repeated measurement analyses (grouping factors: toluene intensity, exposure duration and noise intensity) and logistic regressions did not reveal significant effects of toluene intensity, of exposure duration and of interactions between toluene intensity and noise intensity. The stratification dependent on noise intensity itself [79 +/- 3 versus 84 +/- 1 dB(A)] was significantly associated with the auditory thresholds. Regarding the missing toluene effects, it was concluded that the threshold level for developing a hearing loss as a result of occupational toluene exposure might be above the actual limit of 50 p.p.m.

Psychomotor performance and subjective symptoms at low level toluene exposure

OBJECTIVES

Possible effects of long term occupational exposure to toluene below the level of 100 ppm on psychomotor performance and subjective symptoms were investigated in a cross sectional approach.

METHODS

From German rotogravure printing plants 278 male workers, mean age 39.8 years, mean duration of employment 14.9 years, were examined. A mean lifetime weighted average exposure (LWAE) of 45.1 ppm toluene in ambient air was found for 154 exposed workers (rotogravure printing area), with a mean current exposure of 24.7 ppm. The corresponding data for a second group of 124 workers with very low exposure (endprocessing area) had LWAE of 9.3 ppm and a current exposure of 3.3 ppm toluene. Psychomotor performance (steadiness, line tracing, aiming, tapping, and peg board) and subjective symptoms were examined.

RESULTS

No significant differences between the two exposure groups were found by analysis of variance (ANOVA). By stepwise linear regression analyses there were weak associations of LWAE with one performance variable and two symptoms scales, but the results were not significant after correction for the alpha error. Psychomotor performance was mostly affected by age (maximum explained variance up to 13%), and handedness (up to 9%), whereas subjective symptoms are mostly affected by anxiety (up to 38%).

CONCLUSIONS

The weak associations between long term exposure to toluene should be used to indicate further longitudinal investigations. The results of this cross sectional study show no obvious dose response relation for psychomotor functions and subjective symptoms among workers exposed to toluene at a current exposure level of 1-88 ppm.

Individual toluene exposure in rotary printing: increasing accuracy of estimation by linear models based on protocols of daily activity and other measures

Industrial exposure varies distinctly both between persons and for each person over time. It is often not possible to measure individual exposure repeatedly due to high costs. Therefore, a method for assessment of exposure is needed that accounts for inter- and intraindividual variability. We consider a strategy suggested by Preller et al. (1995, Scandinavian Journal of Work, Environment, and Health 21, 504-512), the idea of which is to predict exposure on several days via a linear model using additional variables as regressors. Those additional variables are easier to obtain than exposure measurements and are assumed to influence exposure. The paper gives a theoretical proof of the use of this method. An example is given using toluene exposure data from a study in a rotogravure printing plant.

Switching attention--additional aspects for the analysis

Problems related to attentional functions have often been reported within the neurotoxicology of long-term exposure to solvents, but knowledge about neuroanatomical sites involved in this degenerative process is still rare. However, some studies have emphasized the frontal cortex as a region of structural or functional changes in long-term exposed patients or accidental intoxications. Neurobehavioral tests using active switching tasks are widely used to detect frontal lobe dysfunction. Test batteries used in neurotoxicology provide such tasks but standard test interpretations often neglect these aspects. Rotogravure printing workers exclusively exposed to toluene were investigated in a longitudinal study with cross-sectional design. Data from two examination periods are presented. In the first sample 333 male workers were investigated. In the second examination period 278 workers could be retested. The workers differed with respect to level and duration of lifetime exposure to toluene. All subjects completed a neurobehavioral test battery including the task switching attention (EURONES). Different parameters were computed for consecutive trials with constant vs. shifted tasks and repetitions vs. changes of the response direction. In general the expected interaction between the two sequence factors could not be observed. In both examination periods the alternative strategy revealed no marked differences between task/response shifts. Considering the result of previous studies on task/response shifts, the results were highly unexpected. One explanation might be the strong deviations from equality for the relative frequencies of the four sequence conditions, resulting in biased expectancies. These may have superimposed on the basic effects of task shifts. However, in both examination periods weak effects of task shift could be revealed in the subgroup of the long-term exposed workers. In further studies it is necessary to balance conditions more carefully in order to exploit the sensitivity that the measurement of shift costs promises to provide. The exposure-related results of this study support this aspect.

Subjective symptoms due to solvent mixtures, dioxin, and toluene: impact of exposure versus personality factors

In this study, we analyse the impact of personality factors on the frequency of self-reported symptoms for workers under different exposure conditions. Reported symptoms may depend on the level and type of exposure, as well as on personality factors such as trait anxiety of the worker or his general sensitivity with regard to the environment. The employed data stems from three studies: The first study contains information of 60 workers who suspected to be exposed to polychlorined dibenzodioxins and dibenzofuranes (Lifetime Weighted Average Exposure, LWAE, as an index for contact with the substances). The second study concerns 40 workers who are exposed to different concentrations of solvent mixtures in paint manufacturing (LWAE of total hydrocarbons about 10 ppm). The third study includes repeated measurements of two subgroups of workers from rotogravure printing plants who are exposed to different concentrations of toluene: a "high" exposure group (n = 129, LWAE about 46 ppm, current exposure 25 ppm) and a "low" exposure group (n = 96, LWAE for toluene about 9 ppm, current exposure 3 ppm). Trait anxiety, environmental sensitivity, and self-reported symptoms are measured by validated questionnaires and age as well as verbal intelligence are controlled. To determine the effect of the individual characteristics and the different exposures on self-reported symptoms, frequency analyses and variance analyses are conducted and linear models are fitted. For all analyses, trait anxiety explains the highest share of the variance. If there is no effect of the exposure on the reported symptoms (dioxin and low-level toluene study), trait anxiety seems to have a larger explanatory power in comparison with those studies where the exposure has an effect on the reported symptoms (solvent-mixture and high-level toluene study). Neurotoxicological risk analysis has to account for the detected dependence of self-reported symptoms on personality traits: assessments for elevated symptoms should not only be linked to the intensity of exposure but also related to benchmarks derived from the normal variability of personality factors.

Neurobehavioral study on the interactive effects of age and solvent exposure

Initial research revealed interaction effects on health measures between exposure to neurotoxicants and age. Symptom reports of workers were conspicuously increased if high-concentration occupational exposure (e.g. to organic solvents, lead) was combined with age above 54 years. The symptom increase in elderly workers was interpreted as a possible indicator of a biological vulnerable phase or delayed response of former high exposure. A second study of the hypothesized age-exposure interaction was performed with a group of workers who had homogenous exposure to a single organic solvent using a neurobehavioral performance evaluation (the EURO-NES). Workers in the rotogravure printing industry who were exposed to toluene were examined two times with an interval of one year (n =333/278). The sample was stratified by workers with significantly different toluene exposure, printers and end-processing operators, and four age classes (< 31, 31-40, 41-50, > 50). The mean lifetime weighted average exposure (LWAE) varied depending on age classes and years of employment with exposure between 7 and 17 ppm in the operators and between 35 to 62 ppm toluene in the printers. Multivariate analyses revealed a significant performance decrease with age (simple reaction time, symbol digit, switching attention, digit span). Again an interaction between age and exposure was found depending on diverging psychometric performance trends with older age. However, contrary to the hypothesis the group with higher exposures (printers) and older age revealed better performance and less symptoms than the group with lower exposure (end-processing operators). The paradoxical results are explained by differences in the intellectual capability in the oldest strata and a possible reversibility of neurobehavioral effects of former high toluene exposure under the condition of later low exposure. There are no hints of adverse delayed effects of former toluene exposure in a possible vulnerable phase in age over 50 years. The different interaction findings of the initial and present study seem to depend mainly on exposure differences in quality and quantity.

Association of biochemical and subjective indicators of drinking habits with performance on different neurobehavioral tasks

The present paper outlines the association of biochemical and subjective indicators of alcohol consumption. Due to its relevance as a potential confounding variable in occupational neurotoxicology, both sources of information about drinking habits were related to neurobehavioral test performance. A sample of 308 rotogravure printers and control subjects from a cross-sectional longitudinal study in various German printing plants was studied. Duration of employment was 4 months to 44 years (mean = 14.9, sd = 9.67). Mean age was 38.4 years (range 21 - 60). From venous blood samples three parameters considered to be sensitive for increased consumption of alcohol were used. They were carbohydrate-deficient transferrin (CDT), gamma glutamyl transferase (GGT), and mean cell volume (MCV). During the medical interview subjects with any chronic liver disease were identified and excluded from data analysis. Additionally, information about weekly consumption of alcohol was assessed and transformed to grams per day (g/d) values. Neurobehavioral testing included simple reaction time (SPES version), switching attention, symbol digit substitution, and digit span (EURONEST version). Additionally, a questionnaire of neurotoxic complaints was administrated. Other covariates, i.e. verbal ability, history of solvent exposure, and age were controlled. GGT and CDT were elevated in 10.5% and 6.6% of the population. 3.5% of the subjects reported daily consumption higher than 60 gram. There were positive correlations of CDT and GGT with the subjective indicator of drinking habits. The magnitude of these relationships were low, but the associations were significant. MCV was not correlated with subjective reports of drinking habits, but it showed convergent correlations with CDT and GGT. Comparison of these two parameters with performance on neurobehavioral tasks yielded only one negative association, i.e. between the memory-loaded tasks factor and GGT. CDT and subjective estimation of alcohol consumption were not related to any cognitive function tested in this study. Especially, the digits-backward task was negatively correlated with increased GGT.

In search of dose-response relationships of solvent mixtures to neurobehavioural effects in paint manufacturing and painters

Four exposure indices for the evaluation of mixtures of solvents are outlined. The hygienic effect is a relative measure depending on the limit values of the single compounds of the mixture. The cumulative lifetime exposure (CE) and the lifetime-weighted average exposure (LWAE) are approaches based on measurements of total hydrocarbons at workplaces in different time periods. Estimations of litres of solvents used per day years (l/d years) are necessary if air monitoring is not available. Five studies on neurobehavioural effects due to solvent mixtures in paint manufacturing are compared as example for dose-response relations. The best prediction of neurobehavioural dose-response relations seems to be possible using CE and LWAE for total hydrocarbon as the exposure index. Moreover, four studies on neurobehavioural effects due to solvent mixtures in paints and glues are compared. These studies indicate that the index l/d years is helpful in predicting neurobehavioural deficits. Of numerous neurobehavioural tests, the test symbol digit substitution shows the most significant dose-response relations in the studies. For symptom questionnaires these relations appear only occasionally. In principle, associations between doses of solvent mixtures in paints and neurobehavioural effects are reproducible to a limited extent.