[Examining in General Practice: Licensure Examinations in a General Practice Setting]

General practitioners play a major role in the health care of the population. Only a small proportion of patients receives care from specialised consultants, in a hospital or in a university hospital. Most of the patients consult a general practitioner. The strengthening of general practice that is called for in the Master Plan for Medical Studies 2020 in new state examination formats, for instance, means that this central position in patient care will be reflected in studies and examinations in the future. The general medical setting is subject to a specific background with unselected patients and a hermeneutic understanding of cases. The format of the new final examination promotes general medical and interdisciplinary competencies in medical interviewing, physical examination, dealing with diseases that can be treated on an outpatient basis, prevention, and the application of general medical guidelines of ethics and law. The standardised oral-practical examination has newly been designed by the Institute for Medical and Pharmaceutical Examination Questions (IMPP). It includes real patients in an outpatient setting. In eight steps, it integrates communicative and technical examination aspects. Two trained examiners will observe and assess the performance of graduates using standardised evaluation forms. The new examination format was developed in 2019 by the IMPP and faculty from various medical schools, was tested in five general medical teaching practices, revised, and then piloted in fourteen examinations. Standardised specifications for the examination process, spatial equipment, and examiner training were developed by IMPP. With approximately 10,000 examinees per year and two students per examination day, a total of 5,000 examination days will be required in general practices. The expertise of the German College of General Practicioners and Family Physicians (DEGAM), the Society of University Teachers of General Medicine (GHA), and the university locations, together with the great potential as the largest specialist group in Germany suggest that the goal of recruiting and motivation of practices appears achievable. With regard to funding, political decisions are necessary. In an increasingly complex care system, the redesign of the oral-practical examination in the outpatient setting contributes to strengthening interdisciplinary and multi-professional cooperation.

[Specialist examination: Is the current format still up-to-date?]

The non-standardized oral specialist examination is the final step of the specialist medical training in Germany. The debate on its current format has long been at the centre of discussions on further training policies. The purpose of this article is to draw attention to relevant structural deficits of the German specialist examination - also in comparison to German-speaking neighboring countries and pan-European developments - and to provide possible approaches to a more structured oral examination.

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

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

We can also do online - evaluation of the accompanying digital seminar of the elective subject "General Practice" during intership (PJ) at Ruhr-University Bochum

Aim: Due to the lockdown caused by the Corona pandemic, the internship (PJ=practical year) seminars of the elective subject "General Practice" at Ruhr-University Bochum had to be transferred on short notice into online teaching formats via a digital platform. At the end of these new online course, the four students evaluated the comprising 16 teaching units. Methods: The seminars, each comprising four teaching units, took place in online blended-learning units and online events. After completing the seminar program, the four participants filled out a written questionnaire regarding the implementation of digital teaching, quality of teaching content, acceptance as well as advantages and disadvantages of the teaching format. Results: The acceptance of digital teaching was very high among students. Advantages and disadvantages of this teaching format compared to the previous face-to-face events became apparent; a positive assessment of the possibilities of the online format clearly prevailed, as competence-oriented, interactive aspects were very well implemented. Conclusion: Due to the need of switching to digital teachings formats, new, innovative perspectives have arisen for PJ teaching in Bochum as well as for the more distant second location Ostwestfalen-Lippe. This is particularly true with regard to centralised seminar offers despite decentralised training centres. When implementing "new" licensing regulations this creates an opportunity for general practice to include teaching practices in training throughout the country.

Developing a seminar curriculum for the Competence Center for General Practice in Baden-Wuerttemberg - a progress report

Aim: The seminar program of the KWBW Verbundweiterbildungplus® is offered by the Competence Center for Postgraduate Medical Education in Baden-Württemberg (KWBW) for physicians specializing in general practice (GP trainees). Attendance is a voluntary one comprised of 48 curricular units of 45 minutes each per GP trainee. This seminar program is meant to be attended in parallel to the postgraduate medical education in clinic or practice. The intention behind this project was to develop objectives, topics and a feasible structure for a seminar curriculum while taking time and financial constraints into account. Method: The Kern cycle was applied in an open, modified nominal group consensus technique in the form of an iterative process. Participating were 17 experts from the departments of general practice at the universities in Freiburg, Heidelberg, Tuebingen and Ulm, plus a pediatrician. Results: The main objective was defined as empowering GP trainees to independently provide high-quality primary care, including in rural areas. A basic curriculum was defined based on relevant frameworks, such as the 2018 Model Regulation for Postgraduate Medical Training (Musterweiterbildungsordnung/MWBO) and the Competency-based Curriculum General Practice (KCA). Overall, the seminar curriculum has 62 basic modules with 2 curricular units each (e.g. Basic Principles of General Practice, Chest Pain, Billing) and another 58 two-unit modules on variable topics (e.g. digitalization, travel medicine) adding up to 240 (124+116) curricular units. A blueprint with a rotation schedule for all of the teaching sites in Baden-Württemberg allows regular attendance by n=400 GP trainees over a period of five years, with individual variability in terms of program length. Conclusion: The model entails a five-year, flexible program to accompany the postgraduate medical education in general practice which can also be implemented in multicenter programs and those with high enrollments. The model's focus is on acquisition of core competencies for general practice. Despite the current shift to eLearning seminars due to SARS-CoV, the program's implementation is being continued, constantly evaluated, and used to further develop the KWBW Verbundweiterbildungplus® program.

Didactic qualification of teaching staff in primary care medicine - a position paper of the Primary Care Committee of the Society for Medical Education

Having teaching staff with didactic qualifications in university teaching leads to a measurable improvement in academic skills among students. Previous recommendations on the type and scope of medical didactic qualification measures primarily apply to teaching staff at university and in-patient settings. The situation of primary care medicine, which often employs external lecturers and whose teaching takes place to a considerable extent in decentralized training facilities (teaching practices) is not adequately addressed. Taking into account a survey on the status quo at higher education institutions for General Practice in Germany, recommendations for minimum standards are made, based on national and international recommendations on the content and scope of medical didactic qualification measures. These recommendations include preliminary work by the Personnel and Organizational Development in Teaching (POiL) Committee of the Society for Medical Education (GMA), the MedicalTeachingNetwork (MDN), the Society of University Teaching Staff in General Medicine (GHA) as well as the experiences of the committee members, who hail from the field of general medicine, internal medicine and pediatrics amongst others.

Mild Depression in Low Back Pain: the Interaction of Thought Suppression and Stress Plays a Role, Especially in Female Patients

PURPOSE

Mild depression has been shown as a precursor and as a consequence of low back pain, even in early phases of acute or subacute pain. Chronic daily life stress as well as dysfunctional pain-related cognitions such as thought suppression (TS) seem to play a role in the pain-depression cycle; however, the mechanisms of these associations are less understood. Experimentally induced TS, conceived as the attempt to directly suppress sensations such as pain, has been shown to paradoxically cause a delayed and non-volitional return of the suppressed thoughts and sensations and to increase affective distress. These dysfunctional processes are supposed to increase under high cognitive load, such as high stress.

METHOD

In the present cross-sectional study, we for the first time sought to examine a possible interaction between habitual TS and stress on depression in N = 177 patients with subacute low back pain (SLBP), using the following questionnaires: Subscale Thought Suppression from Avoidance-Endurance Questionnaire, Beck Depression Inventory, and Kiel Interview of Subjective Situation. A three-way ANOVA was conducted with two groups of TS (high/low), stress (high/low) and sex as independent factors and depression as dependent.

RESULTS

Results indicated a significant three-way interaction with highest depression scores in female patients showing high TS and high stress. Overall main effects for sex and stress indicated higher depression in women and in highly stressed patients.

CONCLUSION

Our findings support the hypothesis that TS heightens depressive mood under conditions of high cognitive load especially in female patients with SLBP indicating a special vulnerability for depressive mood in women with SLBP.

Three years of experience with a workshop for medical specialty examiners in South Baden: A project report and initial evaluation results

Introduction: An oral exam (30-60 minutes) is administered at the end of every post-graduate medical specialty program or is required to attain additional specialized qualifications. In both undergraduate and post-graduate medical education oral exams are not considered to be very objective or reliable. To improve the quality of exams in medical specialties, the Regional Medical Association for South Baden (Bezirksärztekammer Südbaden) decided in 2013 to offer a training program for head examiners and others responsible for administering exams in medical specialties. Project Description: Following a survey of examiners and examinees conducted from January through June, 2013, on the difficulty level of examination questions, satisfaction with the test, and the need for training in administering exams, the first workshop of its kind was designed. Since 2013, six workshops with a total of 93 participants have been held and evaluated. Results: The evaluations (response rate: 86%) showed a high level of acceptance for the concept behind the training. A large number of participants felt the need to define minimum standards for exams, to standardize the required level of difficulty and the assessment criteria in each subject, and to give examiners the appropriate tools needed to improve the validity and reliability of the exams. Conclusion: Offering a training program for those responsible for administering medical specialty exams appears to be both meaningful and necessary in order to meet the existing need for increased validity and reliability. In light of the initial experiences with this workshop and the differing percentages of failed exam attempts nationwide, the implementation of examiner training is to be recommended in other regions in Germany. In other European countries examiners conducting medical specialty exams undergo appropriate training before administering their first exam.

Quality management of clinical-practical instruction for Practical Year medical students in Germany - proposal for a catalogue of criteria from the German Society of Medical Education

Objectives: Amended in 2013, the current version of the German Medical Licensure Regulation contains structural specifications that are also required of non-university institutions involved in Practical Year clinical training. The criteria are worded in relatively general terms. Furthermore, not all of the structural specifications can be readily applied to every subject area. In order to ensure commensurability in Practical Year instruction in Germany, not least in light of recently introduced Practical Year mobility, it is necessary to define consistent quality criteria for Practical Year training. The authors therefore propose a catalogue of criteria for the quality management process in Practical Year instruction facilities.

Methods: In January 2014, the board of directors of the German Society for Medical Education decided to establish a committee comprised of representatives from various German medical faculties. In a process similar to the Delphi methodology, the group developed criteria for structure, process and outcome quality in Practical Year training in Germany.

Results: The criteria developed for structure, process and outcome quality apply to Practical Year training in academic teaching hospitals and university medical centres. Furthermore, modalities for review are proposed.

Conclusions: The present catalogue of criteria is intended to contribute to the formation of a basis for the most consistent quality standards possible for Practical Year instruction in Germany.

Recommendations for undergraduate training in the primary care sector--position paper of the GMA-Primary Care Committee

During their studies to become medical professionals, all students are obliged to become familiar with various aspects of primary care. The aim is to provide all students with a high quality training which ensures the best possible cooperation across all sectors of the medical system.

Primary care comprises the primary use of the medical service by an unfiltered set of patients as well as continued patient care – including home-care.

This position paper was developed together with representatives of the German Society of University Teachers of General Practice (GHA), the German Society for Ambulatory General Paediatrics (DGAAP), the German Society of General Practice and Family Medicine (DEGAM) and the German Society for Internal Medicine (DGIM).

It includes recommendations for teaching in the field of primary care in four different types of internships such as preclinical work experience (“Hospitation”), 4-week clinical traineeships of a casual nature (“Famulatur”) and 2-week courses of structured and assessed clinical training (“Blockpraktikum”) as well as a broad-based 4-month elective clinical placement in the final year (known as a practical year, “PJ”).

The recommendations encompass structural and process criteria for internships in different general practices.

In addition, for the first time recommendations for teaching on campus – in the fields of general medicine, paediatrics, numerous cross-sectional areas and other clinical fields, but also for clinical skills training – are set down here.

In this position paper the intention is to demonstrate the possible ways in which more aspects of primary care could be integrated into undergraduate medical training.

Comparison of collegial individual and group reviews of general practice multiple choice questions

AIMS

In most German medical faculties, credits in general practice can be earned via exams using multiple-choice questions (MCQ). Measures such as peer-reviews may help assure the quality of these exams. In order to use time and personnel intensive peer reviews effectively and efficiently, the procedures used are key. Therefore, we wanted to find out whether there are differences between group and individual reviews regarding defined parameters.

METHODS

We conducted a controlled cross-over study with three GP reviewers from four different German universities. Each reviewed 80 MCQs, 40 individually and 40 within a group, including external assessments by a panel of experts. Furthermore all reviewers were asked to evaluate the review process and the time spent carrying out these reviews.

OUTCOMES

We found no significant differences between the reliability and the validity of individual reviews versus group reviews. On average slightly more time was spent on group reviews compared with the individual reviews. The subjective assessments of the study participants regarding their satisfaction with the process and the efficiency and effectiveness of the reviews suggest a preference for group reviews.

CONCLUSIONS

Based on this study, there are no definite recommendations for or against either approach. When choosing between the two, the specific work structures and organisation at the local faculty should be taken into account.

Promotion of family-friendliness at the Medical Faculty of Freiburg - taking stock of study participation

The survey on family-friendly study organisation in medical schools conducted by the University Hospital in Ulm has identified a need for improvement in various respects in Freiburg. Due to the specific structure of medical school and the high amount of mandatory lectures, students with children face serious problems in balancing family life and their studies at the same time. On the other hand, the freer, modular structure of the clinical curriculum in Freiburg has been mainly rated as positive by the interviewees. In order to improve the situation of students with children, the interviewees favour a more flexible curriculum in general as well as an increase in information and advice services offered by the faculty. In the first place, the results of the study encourage us to maintain the modular structure in the final two clinical years in Freiburg in view of current curriculum developments. Additionally, we aim to offer targeted support to students with children. Furthermore, a wider range of e-learning supported lectures is to help students manage their studies with childcare and family obligations.