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BackgroundIn light of the accumulating evidence, awareness and urgency to act upon the three planetary crises – climate change, biodiversity loss, and pollution – the concept of Planetary Health underscores their profound implications for health and promotes actionable solutions to advance both wellbeing and ecological sustainability. Despite (inter)national calls to integrate Planetary Health into health workers’ curricula, the current status of Planetary Health Education in undergraduate medical education in Germany is unclear. This study therefore aimed (a) to assess the current implementation of Planetary Health in undergraduate medical education in Germany and (b) to explore its characteristics as a foundation to develop evidence-informed recommendations for mainstreaming Planetary Health Education in medical schools in Germany.MethodsThe study comprised structured interviews followed by an online survey, both targeting all 39 medical schools in Germany. In 2021, structured interviews were conducted with students, educators and deanery staff at medical schools. In 2023, educators and deanery staff participated in an online survey based on the findings from the interviews.FindingsIn total, 80% of the 39 medical schools participated in the interviews, while 90% took part in the online survey. Based on integrated findings, 35 medical schools (90%) offered Planetary Health Education, with a median of two educational activities, including both stand-alone courses and lectures integrated into other courses. Despite an overall increase since winter semester 2021/2022, most educational activities were electives and not part of the mandatory curriculum. Innovative educational approaches and learning objectives differed significantly between mandatory and elective formats. In contrast to mandatory educational activities, student involvement was reported for the majority of electives and was significantly associated with transformative learning objectives.InterpretationDespite a steady rise in teaching activities, mandatory Planetary Health Education remains insufficiently integrated into undergraduate medical education in Germany. Key criteria defining high-quality Planetary Health Education, such as innovative educational approaches, practical skills, and transformative learning, were primarily reflected in electives, that reach only a minority of students. To adequately equip the future healthcare workforce, the current barriers to successfully integrating Planetary Health into medical education must be systematically addressed and overcome.

Abstract Background Health professionals are increasingly called upon and willing to engage in planetary health care and management. However, so far, this topic is rarely covered in medical curricula. As the need for professional communication is particularly high in this subject area, this study aimed to evaluate whether the objective structured clinical examination (OSCE) could be used as an accompanying teaching tool. Methods During the winter semester 2022/2023, 20 third- and fifth-year medical students voluntarily participated in a self-directed online course, three workshops, and a formal eight-station OSCE on planetary health care and management. Each examinee was also charged alternatingly as a shadower with the role of providing feedback. Experienced examiners rated students’ performance using a scoring system supported by tablet computers. Examiners and shadowers provided timely feedback on candidates` performance in the OSCE. Immediately after the OSCE, students were asked about their experience using a nine-point Likert-scale survey and a videotaped group interview. Quantitative analysis included the presentation of the proportional distribution of student responses to the survey and of box plots showing percentages of maximum scores for the OSCE performance. The student group interview was analyzed qualitatively. Results Depending on the sub-theme, 60% -100% of students rated the subject of planetary health as likely to be useful in their professional lives. Similar proportions (57%-100%) were in favour of integrating planetary health into required courses. Students perceived learning success from OSCE experience and feedback as higher compared to that from online courses and workshops. Even shadowers learned from observation and feedback discussions. Examiners assessed students’ OSCE performance at a median of 80% (interquartile range: 83%-77%) of the maximum score. Conclusions OSCE can be used as an accompanying teaching tool for advanced students on the topic of planetary health care and management. It supports learning outcomes, particularly in terms of communication skills to sensitise and empower dialogue partners, and to initiate adaptation steps at the level of individual patients and local communities.

Abstract Background Most medical students in Germany are admitted via selection procedures, which are adjusted to the demands of the universities. At Lübeck medical school, scores from interviews that measure non-academic skills and pre-university GPAs are summed to arrive at an admission decision. This article seeks to illuminate the effectiveness of this selection procedure in comparison to other non-selected student groups. Methods Quota information and exam results from the first federal exam were linked for students admitted to Lübeck medical school between 2012 and 2015 (N = 655). Five different student groups (university-specific selection quota, pre-university GPA quota, waiting time quota, ex-ante quota and foreign students) were compared regarding exam attempts, written and oral grades, temporal continuity and examination success in the standard study period. Results While the pre-university GPA quota outperformed all other quotas regarding written and oral grades, it did not differ from the selection quota regarding exam attempts, temporal continuity and examination success in the standard study period. Students in the waiting time and ex-ante quotas performed inferior by comparison. The results of foreign students were the most problematic. Conclusion Students selected by the university show high temporal continuity and examination success. These results, and possible advantages in physician eligibility, argue for the utilisation of non-academic skills for admission.

ObjectiveThe relevance of communication in medical education is continuously increasing. At the Medical Faculty of Hamburg, the communication curriculum was further developed and optimized during this project. This article aims to describe the stakeholders' perceived challenges and supporting factors in the implementation and optimization processes.MethodsThe initial communication curriculum and its development after a one-year optimization process were assessed with a curricular mapping. A SWOT analysis and group discussions were carried out to provide information on the need for optimization and on challenges the different stakeholders faced.ResultsThe curricular mapping showed that the communication curriculum is comprehensive, coherent, integrated and longitudinal. In both the implementation and the project-related optimization processes, support from the dean, cooperation among all stakeholders and structural prerequisites were deemed the most critical factors for successfully integrating communication content into the curriculum.ConclusionThe initiative and support of all stakeholders, including the dean, teachers and students, were crucial for the project's success.Practice implicationsAlthough the implementation of a communication curriculum is recommended for all medical faculties, their actual implementation processes may differ. In a "top-down" and "bottom-up" approach, all stakeholders should be continuously involved in the process to ensure successful integration.

Abstract Background Despite improvements in diagnostics and therapy, the majority of lung tumours are diagnosed at advanced stage IV with a poor prognosis. Due to the nature of an incurable disease, patients need to engage in shared decision making on advance care planning. To implement this in clinical practice, effective communication between patients, caregivers and healthcare professionals is essential. The Heidelberg Milestones Communication Approach (MCA) is delivered by a specifically trained interprofessional tandem and consists of four milestone conversations (MCs) at pivotal times in the disease trajectory. MC 1 (Diagnosis): i.e. prognosis; MC 2 (Stable disease): i.e. prognostic awareness; MC 3 (Progression): i.e. reassessment; MC 4 (Best supportive care): i.e. end of treatment. In between MCs, follow-up calls are carried out to sustain communication. This study aimed to assess to what extent the MCA was implemented as planned and consolidated in specialized oncology practice. Methods A prospective observational process evaluation study was conducted, which focused on the implementation fidelity of the MCA. All MCs during two assessment periods were included. We analysed all written records of the conversations, which are part of the routine documentation during MCs and follow-up calls. Adherence to key aspects of the manual was documented on structured checklists at the beginning of the implementation of the MCA and after 6 months. The analysis was descriptive. Differences between the two assessment periods are analysed with chi-square tests. Results A total of 133 MCs and 54 follow-up-calls (t1) and of 172 MCs and 92 follow-up calls (t2) were analysed. MC 2 were the most frequently completed conversations (n = 51 and n = 47). Advance care planning was discussed in 26 and 13% of MC 2 in the respective assessment periods; in 31 and 47% of MC 2, prognostic awareness was recorded. The most frequently documented topic in the follow-up calls was the physical condition in patients (82 and 83%). Conclusion The implementation of a trajectory-specific communication concept was largely successful. Additional studies are needed to understand how fidelity could be further improved. Trial registration DRKS00013469 / Date of registration: 22.12.2017.

Due to comprehensive social distancing measures related to the COVID-19 pandemic, medical faculties worldwide have made a virtue of necessity in resorting to online teaching. Medical faculties grapple with how to convey clinical competencies to students in this context. There is a need for research not only to map but also to explain the effect of these secondary measures on students’ learning and mental wellbeing. During a period of ongoing comprehensive social distancing measures in Germany, we translated a competency-based curriculum including obstetrics, paediatrics, and human genetics to an e-learning course based on online patient and teacher encounters. In our qualitative study on students’ and teachers’ views, we identify potential enablers and drivers as well as barriers and challenges to undergraduate medical education under lockdown. In summer 2020, we conducted six focus group interviews to investigate medical students’ and teachers’ perspectives, experiences and attitudes. All focus groups were videotaped, transcribed verbatim and coded. To guide our deductive and inductive analysis, we applied the theoretical framework of Regmi and Jones. Content analysis was performed in a multi-perspective group. We identified five major themes contributing to a successful use of clinical competency-based e-learning under lockdown: Communication (with teachers, students, and patients), Mental wellbeing, Structure and self-organization, Technical issues, and Learning and commitment. We discuss enablers and potential barriers within all themes and their overlap and link them in an explanatory model. In our setting, students and teachers find e-learning holds strong potential and especially in times of COVID-19 it is greatly appreciated. We broaden the understanding of the impact of distant learning on acquiring competencies, on attitudes, and on mental wellbeing. Our model may serve for a thoughtful, necessary transition to future e-learning and hybrid programs for a competency-based medical education with ongoing social distancing measures.

Abstract Background Depressive symptoms are common in patients with coronary artery disease (CAD) and are associated with an unfavourable outcome. Establishing prognostic patient profiles prior to the beginning of mental health care may facilitate higher efficacy of targeted interventions. The aim of the current study was to identify sociodemographic and somatic predictors of depression outcome among depressed patients with CAD. Methods Based on the dataset of the multicentre SPIRR-CAD randomised controlled trial (n = 570 patients with CAD and ≥ 8 points on the Hospital Anxiety and Depression Scale (HADS)), 141 potential sociodemographic and somatic predictors of the change in the HADS-D depression score from baseline to 18-month-follow-up were derived in two different ways. We screened for univariable association with response, using either analysis of (co)variance or logistic regression, respectively, both adjusted for baseline HADS-D value and treatment group. To guard against overfitting, multivariable association was evaluated by a linear or binomial (generalised) linear model with lasso regularisation, a machine learning approach. Outcome measures were the change in continuous HADS-D depression scores, as well as three established binary criteria. The Charlson Comorbidity Index (CCI) was calculated to assess possible influences of comorbidities on our results and was also entered in our machine learning approach. Results Higher age (p = 0.002), unknown previous myocardial infarction (p = 0.013), and a higher heart rate variability during numeracy tests (p = .020) were univariably associated with a favourable depression outcome, whereas hyperuricemia (p ≤ 0.003), higher triglycerides (p = 0.014), NYHA class III (p ≤ 0.028), state after resuscitation (p ≤ 0.042), intake of thyroid hormones (p = 0.007), antidiabetic drugs (p = 0.015), analgesic drugs (p = 0.027), beta blockers (p = 0.035), uric acid drugs (p ≤ 0.039), and anticholinergic drugs (p = 0.045) were associated with an adverse effect on the HADS-D depression score. In all analyses, no significant differences between study arms could be found and physical comorbidities also had no significant influence on our results. Conclusion Our findings may contribute to identification of somatic and sociodemographic predictors of depression outcome in patients with CAD. The unexpected effects of specific medication require further clarification and further research is needed to establish a causal association between depression outcome and our predictors. Trial registration www.clinicaltrials.gov NCT00705965 (registered 27th of June, 2008). www.isrctn.com ISRCTN76240576 (registered 27th of March, 2008).

Abstract Background The care needs of patients with a limited prognosis (

An amendment to this paper has been published and can be accessed via the original article.

Background: It is well accepted that medical faculty teaching staff require an understanding of educational theory and pedagogical methods for effective medical teaching. The purpose of this study was to evaluate the effectiveness of a 5-day teaching education program. Methods: An open prospective interventional study using quantitative and qualitative instruments was performed, covering all four levels of the Kirkpatrick model: Evaluation of 1) ‘Reaction’ on a professional and emotional level using standardized questionnaires; 2) ‘Learning’ applying a multiple choice test; 3) ‘Behavior’ by self-, peer-, and expert assessment of teaching sessions with semistructured interviews; and 4) ‘Results’ from student evaluations. Results: Our data indicate the success of the educational intervention at all observed levels. 1) Reaction: The participants showed a high acceptance of the instructional content. 2) Learning: There was a significant increase in knowledge (P

BACKGROUND: The management of patients with heart failure (HF) needs to account for changeable and complex individual clinical characteristics. The use of renin angiotensin system inhibitors (RAAS-I) to target doses is recommended by guidelines. But physicians seemingly do not sufficiently follow this recommendation, while little is known about the physician and patient predictors of adherence. METHODS: To examine the coherence of primary care (PC) physicians' knowledge and self-perceived competencies regarding RAAS-I with their respective prescribing behavior being related to patient-associated barriers. Cross-sectional follow-up study after a randomized medical educational intervention trial with a seven month observation period. PC physicians (n = 37) and patients with systolic HF (n = 168) from practices in Baden-Wuerttemberg. Measurements were knowledge (blueprint-based multiple choice test), self-perceived competencies (questionnaire on global confidence in the therapy and on frequency of use of RAAS-I), and patient variables (age, gender, NYHA functional status, blood pressure, potassium level, renal function). Prescribing was collected from the trials' documentation. The target variable consisted of ≥50% of recommended RAAS-I dosage being investigated by two-level logistic regression models. RESULTS: Patients (69% male, mean age 68.8 years) showed symptomatic and objectified left ventricular (NYHA II vs. III/IV: 51% vs. 49% and mean LVEF 33.3%) and renal (GFR

BACKGROUND: The effectiveness of skills laboratory training is widely recognized. Yet, the transfer of procedural skills acquired in skills laboratories into clinical practice has rarely been investigated. We conducted a prospective, randomised, double-blind, controlled trial to evaluate, if students having trained intravenous (IV) cannulation in a skills laboratory are rated as more professional regarding technical and communication skills compared to students who underwent bedside teaching when assessed objectively by independent video assessors and subjectively by patients. METHODOLOGY AND PRINCIPAL FINDINGS: 84 volunteer first-year medical students were randomly assigned to one of two groups. Three drop-outs occurred. The intervention group (IG; n = 41) trained IV cannulation in a skills laboratory receiving instruction after Peyton's 'Four-Step Approach'. The control group (CG; n = 40) received a bedside teaching session with volunteer students acting as patients. Afterwards, performance of IV cannulation of both groups in a clinical setting with students acting as patients was video-recorded. Two independent, blinded video assessors scored students' performance using binary checklists (BC) and the Integrated Procedural Protocol Instrument (IPPI). Patients assessed students' performance with the Communication Assessment Tool (CAT) and a modified IPPI. IG required significantly shorter time needed for the performance on a patient (IG: 595.4 SD(188.1)s; CG: 692.7 SD(247.8)s; 95%CI 23.5 s to 45.1 s; p = 0.049) and completed significantly more single steps of the procedure correctly (IG: 64% SD(14) for BC items; CG: 53% SD(18); 95%CI 10.25% to 11.75%; p = 0.004). IG also scored significantly better on IPPI ratings (median: IG: 3.1; CG: 3.6; p = 0.015;). Rated by patients, students' performance and patient-physician communication did not significantly differ between groups. CONCLUSIONS: Transfer of IV cannulation-related skills acquired in a skills laboratory is superior to bedside teaching when rated by independent video raters by means of IPPI and BC. It enables students to perform IV cannulation more professionally on volunteer students acting as patients.