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Introduction Inadequate smoking cessation interventions by physicians have been attributed to lack of training, and it is generally thought that additional education will improve patient care. However, interventions aimed at increasing knowledge and practical skills only address one determinant of behavior (capability). This prospective study assessed how much a teaching session for general practitioner (GP) trainees enrolled in Vocational Training Schemes in England also affected two other determinants (motivation and opportunity) specified by the COM-B theory of behavior. Methods Between October and December 2015, GP trainees were given a 3.5-h training session in the theory and practice of smoking cessation. Questionnaires addressed motivation, capability, and opportunities to provide evidence-based brief advice to smokers at the beginning and end of the session, and 3 months later. They also looked at the recollection of previous teaching as well as knowledge, skills, intervention frequency, and perceived barriers against providing interventions. Results Participants (n = 123) remembered little previous training on the subject and self-reported presession knowledge was minimal. Motivation was high throughout while capability and opportunity increased considerably during the session. No further change in these parameters was noted at 3 months. The proportion of participants stating they provided evidence-based brief advice to >50% of smokers increased from 25.2% before the session to 57.7% at follow-up. Lack of time remained a commonly cited barrier. Conclusions Training elicited an immediate and sustained effect on capability, perceived opportunity, and behavior itself. While perceived barriers referring to capability were greatly reduced, barriers referring to opportunity (eg, lack of time) persisted. Implications This is the first study evaluating a GP training session on smoking cessation with regard to the COM-B model. In a pre-post design with 3-month follow-up, we observed substantial and sustained changes in GP trainees' perceived capability and opportunity to provide evidence-based very brief advice, and these increases were paralleled by favorable changes in practice behavior. [ABSTRACT FROM AUTHOR]

Context Clinical reasoning is an essential skill, the foundations of which should be acquired during undergraduate medical education. Student performance in clinical reasoning can be assessed using key feature examinations. However, within a paradigm of test-enhanced learning, such examinations may also be used to enhance long-term retention of procedural knowledge relevant to clinical reasoning. Objectives This study tested the hypothesis that repeated testing with key feature questions is more effective than repeated case-based learning in fostering clinical reasoning. Methods In this randomised crossover trial, Year 4 medical students attended 10 weekly computer-based seminars during which patient case histories covering general medical conditions were displayed. The presentation format was switched between groups every week. In the control condition, students studied long case narratives. The intervention condition used the same content but augmented case presentation with a sequence of key feature questions. Using a within-subjects design, student performance on intervention and control items was assessed at 13 weeks (exit examination) and 9 months (retention test) after the first day of term. Results A total of 87 of 124 eligible students provided complete data for the longitudinal analysis (response rate: 70.2%). In the retention test, mean ± standard deviation student scores on intervention items were significantly higher than those on control items (56.0 ± 25.8% versus 48.8 ± 24.7%; p < 0.001). The results remained unchanged after accounting for exposure time in a linear regression analysis that also adjusted for sex and general student performance levels. Conclusions This is the first study to demonstrate an effect of test-enhanced learning on clinical reasoning as assessed with key feature questions. In this randomised trial, repeated testing was more effective than repeated case-based learning alone. Curricular implementation of longitudinal key feature testing may considerably enhance student learning outcomes in relevant aspects of clinical medicine. [ABSTRACT FROM AUTHOR]

The article comments on the role of assessments in undergraduate medical education. It references a paper on test-enhanced learning (TEL) in medical education published by D. P. Larsen et al. in 2008. The efficacy of repeated testing in promoting higher-order cognitive functions such as critical thinking is discussed, as well as implementation issues that have a direct bearing on the design of medical school curricula.

Introduction: Smoking cessation is one of the most cost-effective of all health interventions. Physicians are in a strong position to encourage smokers to make a quit attempt and to help them achieve long-term abstinence. Formal teaching on tobacco-related disease, the evidence base of smoking cessation, and practical skills training regarding cessation advice and counseling are therefore important parts of undergraduate medical education. A survey of U.K. medical schools conducted 11 years ago revealed substantial deficits in the curricular coverage of these topics. This study aimed at establishing whether the situation has improved since then. Methods: In 2013, all U.K. medical schools were invited to participate in an online survey of their curricular coverage of tobacco addiction and smoking cessation. Results: Of the 33 medical schools, 22 (67%) schools responded. Health effects of smoking were addressed in more than 90% of curricula, and factual knowledge on nicotine addiction and withdrawal symptoms was covered in 50% of curricula. Only 1 in 3 medical schools offered practical skills training in artificial (i.e., role play) or clinical settings, and 50% of schools did not address smoking in summative assessments. Conclusions: Practical skills training regarding cessation counseling is insufficient at most U.K. medical schools and may have become worse during the last 11 years. Increased curricular coverage—including summative assessments—of these topics would ensure that future physicians are adequately equipped to encourage and support effective evidence-based quit attempts in their patients. [ABSTRACT FROM PUBLISHER]

The evaluation of teaching can be an essential driver for curriculum development. Instruments for teaching evaluation are not only used for the purpose of quality assurance but also in the context of medical education research. Therefore, they must meet the common requirements for reliability and validity. This position paper from the GMA Teaching Evaluation Committee discusses strategic and methodological aspects of evaluation in the context of undergraduate medical education and related courses; and formulates recommendations for the further development of evaluation. First, a four-step approach to the design and implementation of evaluations is presented, then methodological and practical aspects are discussed in more detail. The focus here is on target and confounding variables, survey instruments as well as aspects of implementation and data protection. Finally, possible consequences from evaluation data for the four dimensions of teaching quality (structural and procedural aspects, teachers and outcomes) are discussed. [ABSTRACT FROM AUTHOR]

Introduction: Inadequate smoking cessation interventions by physicians have been attributed to lack of training, and it is generally thought that additional education will improve patient care. However, interventions aimed at increasing knowledge and practical skills only address one determinant of behavior (capability). This prospective study assessed how much a teaching session for general practitioner (GP) trainees enrolled in Vocational Training Schemes in England also affected two other determinants (motivation and opportunity) specified by the COM-B theory of behavior.Methods: Between October and December 2015, GP trainees were given a 3.5-h training session in the theory and practice of smoking cessation. Questionnaires addressed motivation, capability, and opportunities to provide evidence-based brief advice to smokers at the beginning and end of the session, and 3 months later. They also looked at the recollection of previous teaching as well as knowledge, skills, intervention frequency, and perceived barriers against providing interventions.Results: Participants (n = 123) remembered little previous training on the subject and self-reported presession knowledge was minimal. Motivation was high throughout while capability and opportunity increased considerably during the session. No further change in these parameters was noted at 3 months. The proportion of participants stating they provided evidence-based brief advice to >50% of smokers increased from 25.2% before the session to 57.7% at follow-up. Lack of time remained a commonly cited barrier.Conclusions: Training elicited an immediate and sustained effect on capability, perceived opportunity, and behavior itself. While perceived barriers referring to capability were greatly reduced, barriers referring to opportunity (eg, lack of time) persisted.Implications: This is the first study evaluating a GP training session on smoking cessation with regard to the COM-B model. In a pre-post design with 3-month follow-up, we observed substantial and sustained changes in GP trainees' perceived capability and opportunity to provide evidence-based very brief advice, and these increases were paralleled by favorable changes in practice behavior. [ABSTRACT FROM AUTHOR]

Background: Professional and consistent smoking prevention and cessation may avoid many smoking-associated deaths worldwide. Dentists can exert a decisive influence on smoking behavior, as most people regularly visit a dentist. However, only if dentists have been trained sufficiently about the consequences of smoking and of smoking cessation methods might they fulfill this task appropriately. Objectives: The aim of our study was therefore to examine the prevalence of smokers among dental students in Germany, their attitude toward smoking in general, and their knowledge about tobacco-related diseases and smoking cessation programs. Methods: A cross-sectional survey among dental students in Germany was conducted in 2016. Students of the first and tenth semesters were asked to participate in this anonymous survey. The questionnaire included items concerning their own smoking habits, their knowledge about effects of smoking on health, and their attitude toward prevention and cessation in a dental setting. Results: Seven hundred and thirty dental students participated in this survey; 21% of the participating students were smokers. Their knowledge about smoking-related diseases was widespread. Some diseases were rarely known (only in 34% of students) and others were well known (in 99% of the students). Knowledge about health risks of e-cigarettes was low. About 30% of the participating students felt competent to encourage and support patients in cessation strategies; 2 out of 3 students were willing to improve their knowledge in that area. More than 85% confirmed that advice for smoking cessation should be one of the tasks of a dentist. Conclusions: Smoking is common among dental students, their knowledge about smoking-related health risks is moderate, and self-perceived smoking cessation skills are poor. More emphasis should be placed on education regarding smoking prevention and cessation methods. [ABSTRACT FROM AUTHOR]

Introduction: Almost half of smoking quit attempts are “spontaneous” (initiated as soon as the decision to quit has been made) and are associated with increased success rates. This study aimed to assess to what extent other factors may account for this association. Methods: Data were used from respondents to a survey representative of the adult population in England from 2006 to 2016. We included 2018 respondents who were current smokers at baseline and had attempted to quit between baseline and 6-month follow-up. Logistic regression models assessed the association between quit success and spontaneous quit attempts while adjusting for smoking, sociodemographic, and quit attempt characteristics. Results: Spontaneous quit attempts were associated with greater odds of quit success (OR = 1.31, 95% CI = 1.07 to 1.60) but the association was not significant in the fully adjusted model (ORadj = 1.19, 95% CI = 0.95 to 1.49). In this adjusted model, those who attempted to quit without cutting down first (ORadj = 3.08, 95% CI = 2.46 to 3.88) and were male (ORadj = 1.44, 95% CI = 1.16 to 1.80) had greater odds of success; although a greater number of attempts in the past 6 months, stronger urges to smoke (strong vs. none), higher daily cigarette consumption, and lower social grade (E vs. AB) were associated with lower odds of success (ORadj range = 0.32–0.98, p < .030). Quit attempts made without cutting down first were correlated with spontaneous quit attempts (r = .150, p < .001) and appeared to account for the diminished association between spontaneous quitting and success (ORadj = 1.18, 95% CI = 0.96 to 1.46). Conclusions: The increased success rate of spontaneous quit attempts appears to be because spontaneous quit attempts are more likely to be made without cutting down first. [ABSTRACT FROM AUTHOR]

Re-establishment of rigor mortis following mechanical loosening is used as part of the complex method for the forensic estimation of the time since death in human bodies and has formerly been reported to occur up to 8-12 h post-mortem (hpm). We recently described our observation of the phenomenon in up to 19 hpm in cases with in-hospital death. Due to the case selection (preceding illness, immobilisation), transfer of these results to forensic cases might be limited. We therefore examined 67 out-of-hospital cases of sudden death with known time points of death. Re-establishment of rigor mortis was positive in 52.2% of cases and was observed up to 20 hpm. In contrast to the current doctrine that a recurrence of rigor mortis is always of a lesser degree than its first manifestation in a given patient, muscular rigidity at re-establishment equalled or even exceeded the degree observed before dissolving in 21 joints. Furthermore, this is the first study to describe that the phenomenon appears to be independent of body or ambient temperature. [ABSTRACT FROM AUTHOR]

Serious games (computer-based learning games) are increasingly used in medical education at various levels, as user access is independent of location and time and promotes non-linear learning. In legal medicine, interactive digital media are still scarce. The freely accessible online serious game "Adventure Legal Medicine" was developed as part of the "Hamburg Open Online University". The goal was to teach the basics of forensic casework in a point-and-click adventure setting consisting of five cases. During development, 40 medical students were asked to evaluate the game anonymously. The System Usability Scale (SUS) resulted in a mean score of 86.7 (SD 8.3), which corresponds to above-average usability. Further specific evaluations revealed a good to very good rating of the game with no differences in terms of gender (p = 0.214), first-year versus advanced students (p = 0.393) and students who never/rarely or sometimes/often played computer games (p = 0.780). Since there are only a few digital media so far that allow curricular integration into undergraduate teaching in legal medicine, this serious game represents a possibility to integrate digital media into both face-to-face teaching and distance learning and to use it as a supplement to the medical school's own teaching offer, encouraging users to actively engage with the subject. [ABSTRACT FROM AUTHOR]

Objective: Clinical reasoning is an essential skill, the foundations of which should be acquired during medical school. Within the format of test-based learning, such examinations can also be used to support the long-term retention of procedural knowledge necessary for clinical reasoning. The aim was to investigate whether repeated exposure to clinical cases in obstetrics and gynecology (OBGYN) with built-in questions leads to higher learning outcome than pure reading cases and what influence the delay between the intervention and the final test has on the retention of the respective content.Methods: In this non-randomised crossover study, 5th-year medical students (duration of the study is 6 years) taking a 1-week clinical attachment in OBGYN participated in computer-based case seminars in winter term 2020/2021, in which different case histories on gynecological-obstetric diseases were presented. Case content was identical for all groups, but the presentation format (cases with key feature questions vs read-only cases) of individual case vignettes changed weekly. The also intervention was repeated after 2 weeks for each group. Knowledge was assessed in an entry and an exit exam consisting of 40 short-answer questions.Results: A total of 94 out of 118 eligible students participated in the study (response rate: 79.7%). Learning outcome was significantly higher for items presented in the key feature format compared to items presented as read-only cases (74.2 ± 8.6% vs. 71.0 ± 9.2%; p = 0.017). Furthermore, the analysis showed that the temporal distance of the intervention package from the final examination had no influence on retention.Conclusion: This is the first study to demonstrate an effect of test-enhanced learning on clinical reasoning in the subject of OGBYN. In this cross-over study, repeated testing was more effective than repeated case-based learning alone. Curricular implementation of longitudinal key feature testing can thus improve learning outcomes for OBGYN. [ABSTRACT FROM AUTHOR]

Validation of examinations is usually based on classical test theory. In this study, we analysed a key feature examination according to item response theory and compared the results with those of a classical test theory approach. Over the course of five years, 805 fourth-year undergraduate students took a key feature examination on general medicine consisting of 30 items. Analyses were run according to a classical test theory approach as well as using item response theory. Classical test theory analyses are reported as item difficulty, discriminatory power, and Cronbach's alpha while item response theory analyses are presented as item characteristics curves, item information curves and a test information function. According to classical test theory findings, the examination was labelled as easy. Analyses according to item response theory more specifically indicated that the examination was most suited to identify struggling students. Furthermore, the analysis allowed for adapting the examination to specific ability ranges by removing items, as well as comparing multiple samples with varying ability ranges. Item response theory analyses revealed results not yielded by classical test theory. Thus, both approaches should be routinely combined to increase the information yield of examination data. [ABSTRACT FROM AUTHOR]

Aims and objectives: Digital teaching, learning and assessment have been part of medical education and continuing education for decades. The objective of this review paper is to highlight developments and perspectives in these areas in the GMS Journal for Medical Education (GMS JME). Methodology: In the spring of 2020, we conducted a systematic literature search of the Journal for Medical Education (JME) and analysed the articles with regard to different categories such as article type, digital tools used or mode of data collection. Results: Of the 132 articles analysed, 78 were digital interventions (53 of which were exploratory-descriptive), 28 were project descriptions, 16 were surveys of needs or equipment and 10 were concept papers. About one-third of the studies and project reports each dealt with virtual patients or case-based learning, whereas no articles were published on trends such as serious games or virtual reality. Overall, our analysis shows that in many respects, the studies on digital teaching were more broadly based, especially between 2006 and 2010, after which this trend tended to decline again. Conclusions: Our analysis shows that publications in the JME consider some key aspects of digital teaching in medical education and continuing education, such as educational videos or virtual patients. The variability of information and methods of presentation advocate the use of guidelines to optimise the quality of scientific papers. Furthermore, clues for future research topics and experimental study designs are identified. [ABSTRACT FROM AUTHOR]

Background: Due to the coronavirus pandemic, the medical faculties in the Federal Republic of Germany converted their curricula to digital formats on a large scale and very quickly in spring 2020 as an emer- gency measure. At the same time, a start was made on the nationwide exchange of digital teaching/learning materials via the online platform “LOOOP share” in order to save local resources. Among other things, virtual patient cases (VP) were shared across faculties for case-based learning, through which students can acquire clinical decision-making skills. Objectives: Within the framework of the cooperation project “National Learning Platforms for Digital Patient-Related Learning in Medical Studies” (DigiPaL), the usability of VPs for students and teachers should be improved, and the spectrum of disease patterns that are covered by VPs should be systematically expanded. Results: With the participation of many locations, a total of 150 VPs were developed by 96 case authors from 16 faculties, in addition to the existing 403 VPs. The thematic selection was made on the basis of criteria oriented to the National Competence Based Catalogue of Learning Objectives for Undergraduate Medical Education (NKLM). After completion, these VPs were also made available to all faculties for free use via “LOOOP share” and the CASUS learning platform. Discussion: Even after the pandemic, these developed VPs should be available to the faculties and thus make a lasting contribution to improve medical training in Germany – especially in light of digital teaching formats being expressly advocated on the basis of the adapted current Medical Licensure Act (ÄApprO). A possible application is interdisciplinary learning of clinical decision-making with the help of blended learning formats within the framework of a longitudinal curriculum. The large number of involved colleagues and faculties shows that the nationally coordinated development of VPs across faculties was commonly seen as useful. [ABSTRACT FROM AUTHOR]

In describing the inverted classroom model (ICM), the following paper is meant to provide an introduction to the subject matter and to serve as a practical guide for those wishing to employ its methods in basic and advanced medical training and education. The ICM is a blended-learning method in which a self-directed learning phase (individual phase) precedes the classroom-instruction phase. During the online phase, factual knowledge is imparted that serves as a basis for the classroom phase. The classroom phase should subsequently be used to assimilate and implement the previously gained knowledge. In contrast, traditional course concepts impart factual knowledge in lectures, for example, or in other face-to-face teachingformats and are followed by the students' self-instruction in order to assimilate this knowledge. The goal of the ICM is the shift from passive learning to accelerated learning in order to foster learning at cognitively demanding levels such as analysis, synthesis and evaluation. The concurrent increase in production and use of screencasts and educational videos, the Open Educational Resources "movement" and the widespread use of Massive Open Online Courses (MOOCS) have contributed to the increased dissemination of the inverted-classroom method. The intention of the present paper is to provide an introduction to the subject matter and simultaneously to offer a short overview of important projects and research results in the field of medical education and other health professions. Furthermore, an outline is given of the advantages and disadvantages of the model as well as its potential benefit to the future of medical education and training. [ABSTRACT FROM AUTHOR]

Dieser Artikel beschreibt die Inverted-Classroom-Methode (ICM) im Sinne einer Einführung in die Thematik und soll als Praxisleitleitfaden für diejenigen dienen, die diese Methode in der medizinischen Aus-, Fort- und Weiterbildungeinsetzen möchten. Es handeltsich bei der ICM um einen Blended-Learning-Methode, bei dem eine Selbstlernphase (individuelle Phase) vor die Präsenzunterrichtsphase gesetzt wird. In der Online-Phase wird Faktenwissen vermittelt, das als Grundlage für die Präsenzphase dient. Die Präsenzphase soll anschließend dafür genutzt werden, das erlernte Wissen zu vertiefen und anzuwenden. Dem gegenüber stehen die traditionellen Kurskonzepte, in denen das Faktenwissen beispielsweise in Vorlesungen oder in anderen Präsenzunterricht-Formaten vermittelt wird und die Vertiefung dieses Wissens durch die Studierenden im Anschluss daran im Selbststudium stattfinden soll. Das Ziel der ICM ist die Verschiebung des passiven Lernens hin zum aktivierenden Lernen, um das Lernen auf kognitiv anspruchvollen Ebenen wie Analyse, Synthese und Evaluation zu unterstützen. Dabei haben die gestiegene Produktion und Nutzung von Screencasts und Lernvideos, die „Bewegung” der „Open Educational Resources” und die verbreitete Nutzung von „Massive Open Online Courses” (MOOCs) zu einer gestiegenen Verbreitung der Inverted-Classroom-Methode beigetragen. Der Artikel soll als Einführung in die Thematik dienen und dabei eine kurze Übersicht über wichtige Projekte und Forschungsergebnisse in der medizinischen Ausbildung und in weiteren Gesundheitsberufen geben. Außerdem werden die Vor- und Nachteile der Methode und ihr potentieller Nutzen für die zukünftige medizinische Aus- und Weiterbildung dargestellt. [ABSTRACT FROM AUTHOR]

Background: The coronavirus pandemic has led to increased use of digital teaching formats in medical education. A number of studies have assessed student satisfaction with these resources. However, there is a lack of studies investigating changes in student performance following the switch from contact to virtual teaching. Specifically, there are no studies linking student use of digital resources to learning outcome and examining predictors of failure. Methods: Student performance before (winter term 2019/20: contact teaching) and during (summer term 2020: no contact teaching) the pandemic was compared prospectively in a cohort of 162 medical students enrolled in the clinical phase of a five-year undergraduate curriculum. Use of and performance in various digital resources (case-based teaching in a modified flipped classroom approach; formative key feature examinations of clinical reasoning; daily multiple choice quizzes) was recorded in summer 2020. Student scores in summative examinations were compared to examination scores in the previous term. Associations between student characteristics, resource use and summative examination results were used to identify predictors of performance. Results: Not all students made complete use of the digital learning resources provided. Timely completion of tasks was associated with superior performance compared to delayed completion. Female students scored significantly fewer points in formative key feature examinations and digital quizzes. Overall, higher rankings within the student cohort (according to summative exams) in winter term 2019/20 as well as male gender predicted summative exam performance in summer 2020. Scores achieved in the first formative key feature examination predicted summative end-of-module exam scores. Conclusions: The association between timely completion of tasks as well as early performance in a module and summative exams might help to identify students at risk and offering help early on. The unexpected gender difference requires further study to determine whether the shift to a digital-only curriculum disadvantages female students. [ABSTRACT FROM AUTHOR]

Introduction: Observational and trial evidence conflict on the efficacy of two contrasting behavioral approaches to quitting smoking-gradual and abrupt. Observational data suggest an abrupt approach to quitting is superior to a gradual approach, whilst trials show no difference. One potential explanation is self-selection in observational data, whereby people can choose their quit approach, and those who find it harder to quit may be more likely to choose a gradual quit approach. This study aims to investigate potential explanations for these conflicting findings.Aims and Methods: This study aims to investigate potential explanations for these conflicting findings. We used observational data from a nationally representative sample of adults in England from November 2006 to February 2020 who reported smoking and had made at least one quit attempt in the past year (n = 21 542). We used logistic regression models to assess the association between abrupt versus gradual quit attempts and quit success, adjusting for sociodemographic, smoking, and quit attempt characteristics.Findings: Abrupt, versus gradual, attempts were associated with improved quit success in an unadjusted model (odds ratio = 2.02, 95% CI = 1.86 to 2.19). This association remained after adjusting for a broad range of relevant confounders (odds ratio = 1.75, 95% CI = 1.59 to 1.93).Conclusions: Among a representative sample of adults who had smoked and made a quit attempt in the past year, there was evidence of an association between abrupt attempts and quit success before and after adjusting for relevant confounders. This suggests that the differences in quit success seen between abrupt and gradual quit attempt types are not completely driven by self-selection in observational data.Implications: We investigated explanations for conflicting findings on the efficacy of gradual versus abrupt approaches to quitting smoking between trial and observational data. Despite adjusting observational data for sociodemographic, smoking, and quit attempt characteristics, an association between abrupt quitting and quit success remained. Therefore, differences in quit success were not completely driven by the self-selection of a gradual approach by people who found it especially difficult to quit or differences in the use of quitting aids. However, characteristics adjusted for were limited by the data available, and future research should continue to investigate the difference in findings across study types to inform cessation support. [ABSTRACT FROM AUTHOR]

Low response rates threaten the reliability and validity of student evaluations of teaching. Previous research has shown that asking students to predict how satisfied their fellow students were with a course produces reliable results at lower response rates. The aim of this study was to investigate whether this prediction-based method can also be used to evaluate student learning outcome. Before and after a cardiorespiratory module, 128 fourth-year medical students provided self-assessments and predictions of performance on 27 specific learning objectives and took formative tests on the respective contents. Pre-post performance gain was compared across all three modalities. Formative exam results indicated a performance gain of 63.0%. Self-assessed and prediction-based performance gains were identical (67.8%) but both slightly overestimated actual performance gain. Irrespective of the method used, a response rate of 20% was sufficient to produce reliable results. Compared to male students, females greatly overestimated their peers' performance which led to inflated performance gain values. Student self-assessments and predictions are equally valid sources of learning outcome measures, and low response rates are sufficient to produce stable results. When using a prediction-based approach, a tendency to overestimate learning outcome in female students needs to be taken into account. [ABSTRACT FROM AUTHOR]

Introduction: In summer term 2020, the clinical phase of the undergraduate medical curriculum at University Medical Center Göttingen was restructured since distance teaching had to be used predominantly due to contact restrictions during the COVID-19 pandemic. This paper investigates the impact of restructuring the clinical curriculum on medical students' satisfaction and learning outcomes. Methods: In each cohort, the 13-week curriculum was divided into two parts: During the first 9 weeks, factual knowledge was imparted using distance teaching by means of a modified inverted classroom approach. This was followed by a 4-week period of adapted classroom teaching involving both real and virtual patients in order to train students' practical skills. The evaluation of the 21 clinical modules comprised students' satisfaction with distance teaching as well as students' learning outcome. The latter was assessed by means of comparative self-assessment (CSA) gain and the results of the module exams, respectively. Data of summer term 2020 (= distance teaching, DT) were compared with respective data of winter term 2019/20 (= classroom teaching, CT) and analysed for differences and correlations. Results: Response rates of evaluations were 51.3% in CT and 19.3% in DT. There was no significant difference between mean scores in module exams in CT and DT, respectively. However, CSA gain was significantly lower in DT (p=0.047) compared with CT. Further analyses revealed that CSA gain depended on the time point of data collection: CSA gain was lower the more time had passed since the end of a specific module. Moreover, we found positive correlations between CSA gain and students' satisfaction with various aspects of distance teaching, particularly with "communication between teachers and students" (rho=0.674; p=0.002). Discussion and conclusions: Although some limitations and confounding factors have to be taken into account (such as evaluation response rates, assessment time points, and proportion of familiar items in module exams), the following recommendations can be derived from our findings: A valid assessment of students' learning outcome by means of exam results requires that as few exam items as possible are familiar to the students. CSA gain seems to be valid if assessment time points are standardised and not contaminated by students' learning activities for other modules. Good communication between teachers and students may contribute to increase students' satisfaction with distance teaching. [ABSTRACT FROM AUTHOR]

The objective of the present study was to investigate the association between angiotensin-converting enzyme (ACE) inhibitor use and cancer incidence (overall, and breast, prostate, and colorectal cancers specifically) in a large representative sample of US adults. Cross-sectional data on cancer diagnosis, timing of cancer diagnosis, ACE inhibitor use, and other characteristics were extracted from 49 512 adults aged ≥ 20 years participating in the National Health and Nutrition Examination Survey (1999–2016). Multivariable-logistic and propensity score matching (PSM) regressions examined the relationship between pre-diagnosis use of ACE inhibitors and diagnosis of all cancers, and breast, prostate, and colorectal cancers specifically. Overall, we observed an increased likelihood of cancer diagnosis [odds ratio (OR) 1.269, 95% confidence interval (CI) 1.088–1.480] among those who used ACE inhibitors compared to non-ACE inhibitor use, and for prostate cancer diagnosis (OR 1.438, 95% CI 1.090–1.897), after adjusting for age, sex, body mass index, race/ethnicity, educational attainment, physical activity, alcohol drinking status, smoking status, and high blood pressure. PSM regression retrieved more conservative estimates such that the increased likelihood of cancer diagnosis was only observed when comparing ACE inhibitor users with non-drug users (OR 1.022, 95% CI 1.016–1.027). Compared with non-ACE inhibitor use, ACE inhibitor use was associated with an increased risk of prostate cancer. In conclusion, in this large representative sample of US adults, it was found that ACE inhibitor use may have a marginal influence on some cancers. [ABSTRACT FROM AUTHOR]

Introduction: Verifying self-reports of smoking abstinence is challenging in studies that involve remote data collection. Resting heart rate (HR) decreases during smoking abstinence. This study assessed whether a decrease in resting HR measured using freely available smartphone apps could potentially be used to verify smoking abstinence.Methods: This study involved a repeated measures experimental design, with data collection in natural setting. Participants were 18 adult, daily smokers. They recorded resting HR in beats per minute (bpm) using freely available smartphone apps during five timepoints (two in the morning and three postnoon) on each of 3 days. The outcome measure was the mean of the postnoon HR recordings. The experimental condition for each of the 3 days (counterbalanced order) was as follows: (1) smoking as usual, (2) not smoking without nicotine replacement therapy (NRT), or (3) not smoking but using NRT. Abstinence was verified using expired-air carbon monoxide (CO) concentration.Results: Compared with the smoking as usual condition, mean HR was 13.4 bpm lower (95% confidence interval [CI] = 5.4 to 21.4, p = .001) in the not smoking without NRT condition and 10.4 bpm lower (95% CI = 3.1 to 17.8, p = 0.004) in the not smoking with NRT condition. There was no statistically significant difference in HR between the two not smoking conditions (p = .39). Abstinence during not smoking days without and with NRT was CO-verified in 18/18 and in 16/18 cases, respectively.Conclusions: Self-recording of resting HR in natural setting using smartphone apps shows a reliable decrease in response to smoking abstinence and may provide a basis for remote verification in smoking cessation studies.Implications: Remote verification of self-reported abstinence in smoking cessation studies remains challenging. Smoking abstinence has been shown to decrease resting HR under laboratory conditions. This study demonstrated that self-recording using freely available smartphone apps shows reliable decreases in resting HR during smoking abstinence and may provide a basis for inexpensive remote verification of smoking abstinence. [ABSTRACT FROM AUTHOR]

Background: Smoking is one of the world's major health problems and dental professionals are in a unique position to promote smoking cessation. However, according to the current literature, neither dental students nor dentists feel adequately prepared to counsel smokers. The purpose of this study was to develop and implement a teaching intervention on smoking cessation for fourth‐year dental students and assess its effectiveness in terms of learning outcome on knowledge, communication skills and attitudes. Materials and Methods: In this prospective intervention study, students in the intervention group (n = 28) participated in a teaching module consisting of a podcast, an interactive lecture, a seminar, and small‐group sessions with role‐play interactions. Knowledge, communication skills and attitudes were measured using written examinations and an objective structured clinical examination (OSCE) at the end of the module and 6 months later. Results were compared with data from a historical control group (n = 27) receiving standard teaching. Results: Compared with the control group, students in the intervention group had higher scores in the knowledge test (67.1% vs 41.8%; P <.001; d = 2.8) as well as in the OSCE (74.9% vs 44.7%; P <.001; d = 2.3) and also retained more knowledge (52.7% vs 36.5%; P <.001; d = 2.0) and skills (71.8% vs 47.6%; P <.001; d = 2.5) over a period of 6 months. Attitudes were similar across groups and time‐points. Conclusion: The teaching intervention equipped dental students with specific knowledge and skills required to effectively counsel smoking patients. Further research is required to assess the transfer of these skills to the clinical setting. [ABSTRACT FROM AUTHOR]

Background: Little is known about evaluation practices as well as performance-oriented allocation of resources according to teaching quality at German medical schools. For this reason, the Association of the Scientific Medical Societies in Germany and the German Association of Medical Faculties aimed to analyse current practices at German medical schools. Methods: Data were collected by a questionnaire which was sent to all medical schools in Germany. Results: 30 medical schools with 33 undergraduate medical programs participated in the survey (response rate: 83%). The evaluation tools used at these schools mainly assessed structural and procedural aspects of teaching and were designed to obtain overall student ratings of teaching quality. Evaluation tools were quite heterogeneous across the sample, and some uncertainty remained with regard to the psychometric properties of these tools and whether they meet international quality standards. Various algorithms underlying resource allocation for teaching are being used, but most focus on quantity rather than quality of teaching. Conclusion: A nationwide agreement on a generalizable definition of high-quality teaching is desirable. At the same time, reliable and valid tools measuring teaching quality need to be identified and/or created. This could be accomplished through a wider collaboration of medical schools and could represent an advancement for the allocation of resources for high-quality teaching. [ABSTRACT FROM AUTHOR]

Post-mortem chemical excitability of the iris is one of the non-temperature-based methods in forensic diagnosis of the time since death. Although several authors reported on their findings, using different measurement methods, currently used time limits are based on a single dissertation which has recently been doubted to be applicable for forensic purpose. We investigated changes in pupil-iris ratio after application of acetylcholine (n = 79) or tropicamide (n = 58) and in controls at upper and lower time limits that are suggested in the current literature, using a digital photography-based measurement method with excellent reliability. We observed "positive," "negative," and "paradox" reactions in both intervention and control conditions at all investigated post-mortem time points, suggesting spontaneous changes in pupil size to be causative for the finding. According to our observations, post-mortem chemical excitability of the iris should not be used in forensic death time estimation, as results may cause false conclusions regarding the correct time point of death and might therefore be strongly misleading. [ABSTRACT FROM AUTHOR]

Introduction: Serious Games are increasingly being used in undergraduate medical education. They are usually intended to enhance learning with a focus on knowledge acquisition and skills development. According to the current literature, few studies have assessed their effectiveness regarding clinical reasoning (CR). The aim of this prospective study was to compare a Serious Game, the virtual Accident & Emergency department ‘EMERGE’ to small-group problem-based learning (PBL) regarding student learning outcome on clinical reasoning in the short term. Methods: A total of 112 final-year medical students self-selected to participate in ten 90-minute sessions of either small-group PBL or playing EMERGE. CR was assessed in a formative examination consisting of six key feature cases and a final 45-minute EMERGE session. Results: Overall, the EMERGE group (n = 78) scored significantly higher than the PBL group (n = 34) in the key feature examination (62.5 (IQR: 17.7)% vs. 54.2 (IQR: 21.9)%; p = 0.015). There was no significant difference in performance levels between groups regarding those cases which had been discussed in both instructional formats during the training phase. In the final EMERGE session, the EMERGE group achieved significantly better results than the PBL group in all four cases regarding the total score as well as in three of four cases regarding the final diagnosis and the correct therapeutic interventions. Conclusion: EMERGE can be used effectively for CR training in undergraduate medical education. The difference in key feature exam scores was driven by additional exposure to more cases in EMERGE compared to PBL despite identical learning time in both instructional formats. EMERGE is a potential alternative to intensive small-group teaching. Further work is needed to establish how Serious Games enhance CR most effectively. [ABSTRACT FROM AUTHOR]

Summary: Background: Student evaluations of teaching can provide useful feedback for teachers and programme coordinators alike. We have designed a novel evaluation tool assessing teacher performance and student learning outcome. This tool was implemented at two German medical schools. In this article, we report student and teacher perceptions of the novel tool, and the implementation process. Methods: Focus group discussions as well as one‐to‐one interviews involving 22 teachers and 31 undergraduate medical students were conducted. Following adjustments to the feedback reports (e.g. the colour coding of results) at one medical school, 42 teachers were asked about their perceptions of the revised report and the personal benefit of the evaluation tool. Results: Teachers appreciated the individual feedback provided by the evaluation tool and stated that they wanted to improve their teaching, based on the results; however, they missed most of the preparative communication. Students were unsure about the additional benefit of the instrument compared with traditional evaluation tools. A majority was unwilling to complete evaluation forms in their spare time, and some felt that the new questionnaire was too long and that the evaluations occurred too often. They were particularly interested in feedback on how their comments have helped to further improve teaching. Student evaluations of teaching can provide useful feedback Conclusion: Despite evidence of the utility of the tool for individual teachers, implementation of changes to the process of evaluation appears to have been suboptimal, mainly owing to a perceived lack of communication. In order to motivate students to provide evaluation data, feedback loops including aims and consequences should be established. [ABSTRACT FROM AUTHOR]

Background:Evaluation is an integral part of curriculum development in medical education. Given the peculiarities of bedside teaching, specific evaluation tools for this instructional format are needed. Development of these tools should be informed by appropriate frameworks. The purpose of this study was to develop a specific evaluation tool for bedside teaching based on the Stanford Faculty Development Program’s clinical teaching framework. Methods:Based on a literature review yielding 47 evaluation items, an 18-item questionnaire was compiled and subsequently completed by undergraduate medical students at two German universities. Reliability and validity were assessed in an exploratory full information item factor analysis (study one) and a confirmatory factor analysis as well as a measurement invariance analysis (study two). Results:The exploratory analysis involving 824 students revealed a three-factor structure. Reliability estimates of the subscales were satisfactory (α = 0.71–0.84). The model yielded satisfactory fit indices in the confirmatory factor analysis involving 1043 students. Discussion:The new questionnaire is short and yet based on a widely-used framework for clinical teaching. The analyses presented here indicate good reliability and validity of the instrument. Future research needs to investigate whether feedback generated from this tool helps to improve teaching quality and student learning outcome. [ABSTRACT FROM PUBLISHER]

A letter to the editor is presented in response to the editorial "Animal Farm" published in the 2014 issue of the journal "Nature."

Background: The prevalence of tobacco smoking in Germany is high (~27%). Monitoring of national patterns of smoking behaviour and data on the "real-world" effectiveness of cessation methods are needed to inform policies and develop campaigns aimed at reducing tobacco-related harm. In England, the Smoking Toolkit Study (STS) has been tracking such indicators since 2006, resulting in the adaptation of tobacco control policies. However, findings cannot be directly transferred into the German health policy context. The German Study on Tobacco Use (DEBRA: "Deutsche Befragung zum Rauchverhalten") aims to provide such nationally representative data.Methods/design: In June 2016, the study started collecting data from computer-assisted, face-to-face household interviews in people aged 14 years and older. Over a period of 3 years, a total of ~36,000 respondents will complete the survey with a new sample of ~2000 respondents every 2 months (=18 waves). This sample will report data on demographics and the use of tobacco and electronic (e-)cigarettes. Per wave, about 500-600 people are expected to be current or recent ex-smokers (<12 months since quitting). This sample will answer detailed questions about smoking behaviour, quit attempts, exposure to health professionals' advice on quitting, and use of cessation aids. Six-month follow-up data will be collected by telephone.Discussion: The DEBRA study will be an important source of data for tobacco control policies, health strategies, and future research. The methodology is closely aligned to the STS, which will allow comparisons with data from England, a country with one of the lowest smoking prevalence rates in Europe (18%).Trial Registration: This study has been registered at the German Clinical Trials Register ( DRKS00011322 ) on 25th November 2016. [ABSTRACT FROM AUTHOR]

Measurement of postmortem pupil width is a potential component of death time estimation. However, no standardized measurement method has been described. We analyzed a total of 71 digital images for pupil–iris ratio using the software ImageJ. Images were analyzed three times by four different examiners. In addition, serial images from 10 cases were taken between 2 and 50 h postmortem to detect spontaneous pupil changes. Intra- and inter-rater reliability of the method was excellent (ICC > 0.95). The method is observer independent and yields consistent results, and images can be digitally stored and re-evaluated. The method seems highly eligible for forensic and scientific purposes. While statistical analysis of spontaneous pupil changes revealed a significant polynomial of quartic degree for postmortem time (p = 0.001), an obvious pattern was not detected. These results do not indicate suitability of spontaneous pupil changes for forensic death time estimation, as formerly suggested. [ABSTRACT FROM AUTHOR]

Purpose: Chronic obstructive pulmonary disease (COPD) is associated with elevated sympathetic nerve activity, which is probably linked to an increased cardiovascular risk, and may contribute to muscle dysfunction by heightened muscle vasoconstrictor drive. We hypothesized that resistive unloading of respiratory muscles by intermittent non-invasive ventilation (NIV) reduces sympathetic tone at rest and during subsequent handgrip exercise in patients with COPD. Methods: Muscle sympathetic nerve activity (MSNA) in the peroneal nerve, heart rate, blood pressure, CO, and SpO were continuously recorded in 5 COPD patients with intermittent NIV and 11 control COPD patients without NIV. Static and dynamic handgrip exercises were performed before and after NIV. Results: At baseline, heart rate-adjusted MSNA (bursts/100 heart beats) did not differ between groups. NIV did not significantly affect MSNA levels at rest. However, during handgrip exercises directly following NIV, MSNA was lower than before, which was significant for dynamic handgrip (67.00 ± 3.70 vs. 62.13 ± 4.50 bursts/100 heart beats; p = 0.035 in paired t test). In contrast, MSNA (non-significantly) increased in the control group during repeated dynamic or static handgrip. During dynamic handgrip, tCO was lower after NIV than before (change by −5.04 ± 0.68 mmHg vs. −0.53 ± 0.64 in the control group; p = 0.021), while systolic and diastolic blood pressure did not change significantly. Conclusions: NIV reduces sympathetic activation during subsequent dynamic handgrip exercise and thereby may elicit positive effects on the cardiovascular system as well as on muscle function in patients with COPD. [ABSTRACT FROM AUTHOR]

Introduction: Physician adherence to guideline recommendations regarding the provision of counseling and support for smokers willing to quit is low. A lack of training during undergraduate medical education has been identified as a potential cause. This prospective intervention study evaluated a novel teaching module for medical students.Methods: As part of a 6-week cardiovascular course, 125 fourth-year undergraduate medical students received a multimodal and interactive teaching module on smoking cessation, including online learning material, lectures, seminars, and practical skills training. Short- and medium-term effects on knowledge, skills, attitudes, and self-reported practice were measured using written examinations and an objective structured clinical examination at the end of the module and 6 months later. Results were compared to data obtained from a historical control cohort (n = 70) unexposed to the intervention.Results: At the 6-month follow-up, scores in the knowledge test were significantly higher in the intervention than the control group (61.1% vs. 51.7%; p < .001). A similar pattern was observed in the objective structured clinical examination (71.5% vs. 60.5%; p < .001). More students in the intervention than control group agreed that smoking was a chronic disease (83.1% vs. 68.1%; p = .045). The control group was more likely to report recording smoking status (p = .018), but no group difference was detected regarding the report of advising to quit (p = .154).Conclusions: A novel teaching module for undergraduate medical students produced a sustained learning outcome in terms of knowledge, skills, and attitudes but not self-reported practice.Implications: Studies across the world have identified considerable knowledge gaps and deficits in practical training with regard to smoking cessation counseling in undergraduate medical students. This paper describes a teaching intervention informed by current recommendations for the design of educational activities aimed at enabling medical students to deliver adequate behavior change counseling. The teaching module was tailored to the needs of a specific healthcare system. Given its effectiveness as demonstrated in this prospective study, a rollout of this intervention in medical schools might have the potential to substantially improve medical students' knowledge, skills, and attitudes in relation to smoking cessation counseling. [ABSTRACT FROM AUTHOR]

Background: Lack of smoking cessation education in undergraduate medical training hinders healthcare professionals in providing adequate tobacco cessation counselling. We developed a comprehensive 4-h smoking cessation counselling course for medical students that is easy to incorporate in a medical school curriculum, and assessed its short-term outcome for knowledge, skills, and attitudes. Methods: Eighty-eight medical students (53f, 35 m) were educated by a doctoral student in five identical 4-h courses. A 45-min theoretical introduction was followed by patient-physician role-playing by student pairs. Knowledge, skills, and attitude were assessed before and 4 weeks after the course by questionnaires, and by blinded analysis of pre- and post-course videos of a five-minute standardized patient situation. Results: Knowledge: Before the course 10.6 (mean, SD: 2.7) questions out of 29 were answered correctly, and increased to 19.2 (3.6) after the course (p< 0.0005). Major features of the students' counselling skills improved. Significant and highly relevant attitude changes reflected increased motivation to counselling smokers. Conclusion: Implementing a four-hour smoking intervention workshop into a medical curriculum was highly effective in improving students' knowledge, skills and attitudes towards smoking counselling, as well as providing them with additional clinical competencies. [ABSTRACT FROM AUTHOR]

Exercise intolerance, skeletal muscle dysfunction, and reduced daily activity are central in COPD patients and closely related to quality of life and prognosis. Studies assessing muscle exercise have revealed an increase in sympathetic outflow as a link to muscle hypoperfusion and exercise limitation. Our primary hypothesis was that muscle sympathetic nerve activity (MSNA) correlates with exercise limitation in COPD. MSNA was evaluated at rest and during dynamic or static handgrip exercise. Additionally, we assessed heart rate, blood pressure, CO2 tension, oxygen saturation (SpO2), and breathing frequency. Ergospirometry was performed to evaluate exercise capacity. We assessed MSNA of 14 COPD patients and 8 controls. In patients, MSNA was negatively correlated with peak oxygen uptake (VO2% pred) (r = −0.597;p= 0.040). During dynamic or static handgrip exercise, patients exhibited a significant increase in MSNA, which was not observed in the control group. The increase in MSNA during dynamic handgrip was highly negatively correlated with peak exercise capacity in Watts (w) and peak oxygen uptake (VO2/kg) (r = −0.853; p = 0.002 and r = −0.881; p = 0.002, respectively). Our study reveals an association between increased MSNA and limited exercise capacity in patients with COPD. Furthermore, we found an increased sympathetic response to moderate physical exercise (handgrip), which may contribute to exercise intolerance in COPD. [ABSTRACT FROM PUBLISHER]

Background: Varenicline is an effective smoking cessation medication. Some concern has been raised that its use may precipitate adverse cardiovascular events although no patho-physiological mechanism potentially underlying such an effect has been reported. The aim of this study was to test the hypothesis that varenicline impacts on sympatho-vagal balance during smoking withdrawal. Methods: In this randomised, placebo-controlled trial, muscle sympathetic nerve activity (MSNA), baroreflex sensitivity (BRS), heart rate, and blood pressure were assessed in 17 smokers four weeks before a quit attempt (baseline) and again on the third day of that quit attempt (acute smoking withdrawal). Results: Regarding the primary endpoint of our study, we did not find a significant effect of varenicline compared to placebo on changes in MSNA burst incidence between baseline and acute smoking withdrawal (-3.0 ±3.3 vs.-3.9 ± 5.0 bursts/100 heart beats; p = 0.308). However, heart rate and systolic blood pressure significantly decreased in the placebo group only, while no significant changes in these parameters were observed in the varenicline group. Exposure to smoking cues during acute withdrawal lead to a significant increase of heart rate in the placebo group, while heart rate decreased in the varenicline group, and the difference in these changes was significant between groups (+2.7 ± 1.0 vs.-1.8±0.5 1/min;p = 0.002). In all 17 participants combined, a significant increase in heart rate during smoking cue exposure was detected in subjects who relapsed in the course of six weeks after the quit date compared to those who stayed abstinent (+2.5 ± 1.2 vs.--1.1 ± 0.7; p = 0.018). Six-week abstinence rates were higher in the varenicline group compared to placebo (88 vs. 22 %p = 0.015). Conclusion: We did not find evidence of adverse effects of varenicline on sympatho-vagal balance. Varenicline probably blunts the heart rate response to smoking cues, which may be linked to improved cessation outcome. [ABSTRACT FROM AUTHOR]

Despite ultrasound being an inherent part of medical education, only a few German medical schools have established a comprehensive ultrasound curriculum. This study aimed to explore medical students' perspectives on ultrasound in medical education (USMed). Questionnaire and Distribution. An anonymous, voluntary online survey was developed to collect information regarding student opinions on USMed. The survey consisted of 17 questions, structured into three sections. In total, 1040 questionnaires from 31 medical schools (of total 37) were completed. Between January 1st, 2019 und June 30th, 2019, an online survey was conducted among German medical students via the students' associations and their respective teaching facilities. The survey consisted of 17 items regarding USMed. Statements were rated on a 4-point Likert scale for agreement. In total, 1040 students from 31 German medical faculties participated. The majority (1021, 98.2%) reported a very high to high interest in curricular USMed. Students agreed (n = 945, 90.9%) that USMed would be helpful along their entire course of medical studies. Considering the best starting time for USMed, the opinions of German medical students diverged: students studying in a model curriculum preferred to start in the second year (40.7%) while 49%of the students studying in a traditional curriculum preferred to start in the third year (p ≤ 0.001). An insufficient allotment of time for USMed in the planned curriculum (675, 65%) and a lack of courses run by medical faculty (305, 29.4%) were listed as perceived significant barriers to the participation in USMed. Peer teaching was regarded as an effective method in realizing USMed by 731 (70.3%) students. German medical students are very interested and willing to participate in USMed. There appears to be a high demand for US courses offered by medical schools. [ABSTRACT FROM AUTHOR]

The aim of this study was to clarify whether positive results for prostate-specific antigen ( PSA) and acid phosphatase ( AP) occur in postmortem swabs from the genito-anal region in males ( n = 80; 4 regions) and females ( n = 20; 3 regions) and to calculate the positive predictive value ( PPV) concerning the presence of spermatozoa. In male subjects, the highest incidence of positive test results was found in urethral swabs ( PSA 76%, AP 71%) and the lowest frequencies appeared in perianal and rectal swabs (15-20%). Microscopic evaluation for spermatozoa was positive between 39% in urethral swabs and 1% in rectal swabs. PPV regarding positive identification of spermatozoa was 33.3% for PSA and 31.5% for AP. The combination of both tests yielded a PPV of 38.2%. In female cases, no spermatozoa were identified, and one case was PSA- and AP-positive in perianal swabs. Our findings indicate that PSA and AP tests are of limited value for the postmortem detection of spermatozoa in male subjects. [ABSTRACT FROM AUTHOR]

Forensic medicine can provide access to autopsies for students in undergraduate medical education. Previous qualitative studies reported that attending autopsies promotes learning and is helpful in organising information in the context of self-directed learning, covering cognitive, emotional and societal issues. In the present study, learning outcome regarding specific pathophysiological learning objectives of students who attended an autopsy elective (intervention group, n = 32) was estimated in comparison to peer students who signed up for the course but were not selected (control group A, n = 47) and students who had not signed up (control group B, n = 186). Learning outcome (expressed as a percent knowledge gain) was measured by means of comparative self-assessments (CSA). Furthermore, group interviews were conducted to evaluate the attending students' perceptions and experiences of the course. In the intervention group, the percent knowledge gain for learning objectives reflecting pathophysiological mechanisms was about twice as high than that in the control groups, while all three groups showed comparable knowledge gain for learning objectives covered by mandatory courses that were held during the study period. Results of mandatory post-course assessments showed no statistically significant differences between the intervention and control groups. Therefore, the knowledge gain regarding learning objectives not covered by mandatory courses that was observed in the intervention group reflected the additional benefit of attending the autopsy course. Group interviews with the participants revealed gain of integrated knowledge and understanding of pathophysiological relations as important issues, while negative effects were reported infrequently. Our findings suggest that attendance of a series of autopsies fosters learning and understanding of important issues in medical education and should therefore be part of undergraduate medical curricula wherever possible. [ABSTRACT FROM AUTHOR]

Background Communication skills combined with specialized knowledge are fundamental to the doctor-patient relationship in surgery. During a single-station video-recorded objective structured clinical examination (VOSCE), students were tasked with obtaining informed consent. Our aim was to develop a standardized and quality-assured assessment method in undergraduate education. Methods One hundred fifty-five students in their fifth year of medical school (78 videos) participated in a summative VOSCE within the framework of the teaching module "Operative Medicine." They prepared for three clinical scenarios and the surgical procedures involved. The examination comprised participants having to obtain informed consent from simulated patients, video recording their performance. Students were assessed by two independent raters, the background of one of whom was nonsurgical. Results were statistically tested using SPSS. Results Students' scores were all beyond the pass mark of 70%, averaging 91.0% (±4.0%), 88.4% (±4.4%), and 87.0% (±4.7%) for the appendectomy, cholecystectomy, and inguinal hernia repair checklist, respectively. Most items (68%-89% of the checklists) were found to have fair to excellent discrimination values. Cronbach's α values ranged between 0.565 and 0.605 for the individual checklists. Interrater agreement was strong (Pearson correlation coefficient = 0.80, P < 0.01; intraclass correlation coefficient 2.1 = 0.78). Conclusions The VOSCE is both feasible and reliable as a method of assessing student communication skills and the application of clinical knowledge while obtaining informed consent in surgery. This method is efficient (flexible rating outside normal working hours possible with reductions in administrative load) and may be used for high-stakes evaluation of student performance. [ABSTRACT FROM AUTHOR]

Background: Nicotine replacement therapy (NRT) bought over the counter (OTC) appears to be largely ineffective for smoking cessation, which may be partially explained by poor adherence. We developed and evaluated the NRT2Quit smartphone app (for iOS) designed to improve quit attempts with OTC NRT by improving adherence to the medications.Methods: This study was a pragmatic double-blind randomised controlled trial with remote recruitment through leaflets distributed to over 300 UK-based community pharmacies. The study recruited adult daily smokers (≥10 cigarettes per day) who bought NRT, wanted to quit smoking, downloaded NTR2Quit and completed the registration process within the app. Participants were automatically randomly assigned within the app to the intervention (full) version of NRT2Quit or to its control (minimal) versions. The primary outcome was biochemically verified 4-week abstinence assessed at 8-week follow-up using Russell Standard criteria and intention to treat. Bayes factors were calculated for the cessation outcome. Secondary outcomes were self-reported abstinence, NRT use, app use and satisfaction with the app.Results: The study under-recruited. Only 41 participants (3.5% of the target sample) were randomly assigned to NRT2Quit (n = 16) or the control (n = 25) app versions between March 2015 and September 2016. The follow-up rate was 51.2%. The intervention participants had numerically higher biochemically verified quit rates (25.0% versus 8.0%, P = 0.19, odds ratio = 3.83, 0.61-24.02). The calculated Bayes factor, 1.92, showed that the data were insensitive to test for the hypothesis that the intervention app version aided cessation. The intervention participants had higher median logins (2.5 versus 0, P = 0.01) and were more likely to use NRT at follow-up (100.0% versus 28.6%, P = 0.03) and recommend NRT2Quit to others (100.0% versus 28.6%, P = 0.01).Conclusions: Despite very low recruitment, there was preliminary but inconclusive evidence that NRT2Quit may improve short-term abstinence and adherence among smokers using NRT. Well-powered studies on NRT2Quit are needed, but different recruitment methods will be required to engage smokers through community pharmacies or other channels.Trial Registration: ISRCTN ISRCTN33423896 , prospectively registered on 22 March 2015. [ABSTRACT FROM AUTHOR]

Background: The German clinical guideline on tobacco addiction recommends that general practitioners (GPs) provide brief stop-smoking advice to their patients according to the "5A" or the much briefer "ABC" method, but its implementation is insufficient. A lack of training is one barrier for GPs to provide such advice. Moreover, the respective effectiveness of a 5A or ABC training regarding subsequent delivery of stop-smoking advice has not been investigated. We developed a training for GPs according to both methods, and conducted a pilot study with process evaluation to optimize the trainings according to the needs of GPs. This study aims at evaluating the effectiveness of both trainings. Methods: A pragmatic 2-arm cluster randomised controlled trial with a pre-post data collection will be conducted in 48 GP practices in North Rhine-Westphalia (Germany). GPs will be randomised to receive a 3.5-h-training in delivering either 5A or ABC, including peer coaching and intensive role plays with professional actors. The patient-reported primary outcome (receipt of GP advice to quit: yes/no) and secondary outcomes (recommendation rates of smoking cessation treatments, group comparison (5A versus ABC): receipt of GP advice to quit) will be collected in smoking patients routinely consulting their GP within 4 weeks prior, and 4 weeks following the training. Additional secondary outcomes will be collected at 4, 12 and 26 weeks following the consultation: use of cessation treatments during the last quit attempt (if so) since the GP consultation, and point-prevalence abstinence rates. The primary data analysis will be conducted using a mixed-effects logistic regression model with random effects for the cluster variable. Discussion: If the training increases the rates of delivery of stop-smoking advice, it would offer a low-threshold strategy for the guideline implementation in German primary care. Should one method prove superior, a more specific guideline recommendation can be proposed. Trial registration: German Clinical Trials Register (DRKS00012786); registered on 22th August 2017, prior to the first patient in. [ABSTRACT FROM AUTHOR]

Background: Concerns have been raised that observing other people using e-cigarettes may undermine motivation to quit by renormalising smoking. This study aimed to explore associations between regular exposure to other people's e-cigarette use and motivation to stop smoking and quit attempts in smokers.Methods: Data were from 12,787 smokers in England who participated in the Smoking Toolkit Study between November 2014 and May 2018. At baseline, respondents were asked whether anyone other than themselves regularly used an e-cigarette in their presence, whether they had made a quit attempt in the past year and how motivated they were to stop. Data at 6-month follow-up were available for 1580 respondents, who reported on whether they had attempted to quit in the past 6 months.Results: Smokers who reported regular exposure to e-cigarette use by others were more likely than those who did not to have tried to stop smoking in the past year (32.3% vs. 26.8%; unadjusted RR 1.21, 95% CI 1.11-1.31) and have high motivation to quit (16.6% vs. 14.2%; unadjusted RR 1.17, 95% CI 1.05-1.30) but were not significantly more or less likely to make a quit attempt over the subsequent 6 months (34.4% vs. 31.3%; unadjusted RR 1.10, 95% CI 0.88-1.38). In models that adjusted for participants' own current e-cigarette use and unadjusted and adjusted models excluding current e-cigarette users from the sample, there were no significant associations between exposure to e-cigarette use by others and past quit attempts (RR 0.97-1.00), high current motivation to quit (RR 0.97-1.00) or prospective quit attempts (RR 0.94-1.12). In contrast, exposure to use of cigarettes was associated with low motivation to quit even after adjustment (RR 0.89) but not with quit attempts. Participants' own use of e-cigarette was strongly associated with high motivation to quit (RR 1.95) and past quit attempts (RR 2.14) and appeared to account for the bivariate associations with reported exposure to e-cigarettes.Conclusion: Smokers who report regular exposure to other people using e-cigarettes are more likely to report past quit attempts and high current motivation to quit, but there does not appear to be an independent association with motivation or quit attempts after adjustment for their own current use of e-cigarettes. In contrast, reported exposure to other people using cigarettes was independently and negatively associated with high motivation. [ABSTRACT FROM AUTHOR]

Background: The Choosing Wisely campaign highlights the importance of clinical reasoning abilities for competent and reflective physicians. The principles of this campaign should be addressed in undergraduate medical education. Recent research suggests that answering questions on important steps in patient management promotes knowledge retention. It is less clear whether increasing the authenticity of educational material by the inclusion of videos further enhances learning outcome.Methods: In a prospective randomised controlled cross-over study, we assessed whether repeated video-based testing is more effective than repeated text-based testing in training students to choose appropriate diagnostic tests, arrive at correct diagnoses and identify advisable therapies. Following an entry exam, fourth-year undergraduate medical students attended 10 weekly computer-based seminars during which they studied patient case histories. Each case contained five key feature questions (items) on the diagnosis and treatment of the presented patient. Students were randomly allocated to read text cases (control condition) or watch videos (intervention), and assignment to either text or video was switched between groups every week. Using a within-subjects design, student performance on video-based and text-based items was assessed 13 weeks (exit exam) and 9 months (retention test) after the first day of term. The primary outcome was the within-subject difference in performance on video-based and text-based items in the exit exam.Results: Of 125 eligible students, 93 provided data for all three exams (response rate 74.4%). Percent scores were significantly higher for video-based than for text-based items in the exit exam (76.2 ± 19.4% vs. 72.4 ± 19.1%, p = 0.026) but not the retention test (69.2 ± 20.2% vs. 66.4 ± 20.3%, p = 0.108). An additional Bayesian analysis of this retention test suggested that video-based training is marginally more effective than text-based training in the long term (Bayes factor 2.36). Regardless of presentation format, student responses revealed a high prevalence of erroneous beliefs that, if applied to the clinical context, could place patients at risk.Conclusion: Repeated video-based key feature testing produces superior short-term learning outcome compared to text-based testing. Given the high prevalence of misconceptions, efforts to improve clinical reasoning training in medical education are warranted. The Choosing Wisely campaign lends itself to being part of this process. [ABSTRACT FROM AUTHOR]

Background and Objective: Evaluation is an integral part of education in German medical schools. According to the quality standards set by the German Society for Evaluation, evaluation tools must provide an accurate and fair appraisal of teaching quality. Thus, data collection tools must be highly reliable and valid. This review summarises the current literature on evaluation of medical education with regard to the possible dimensions of teaching quality, the psychometric properties of survey instruments and potential confounding factors.Methods: We searched Pubmed, PsycINFO and PSYNDEX for literature on evaluation in medical education and included studies published up until June 30, 2011 as well as articles identified in the "grey literature". RESULTS are presented as a narrative review.Results: We identified four dimensions of teaching quality: structure, process, teacher characteristics, and outcome. Student ratings are predominantly used to address the first three dimensions, and a number of reliable tools are available for this purpose. However, potential confounders of student ratings pose a threat to the validity of these instruments. Outcome is usually operationalised in terms of student performance on examinations, but methodological problems may limit the usability of these data for evaluation purposes. In addition, not all examinations at German medical schools meet current quality standards.Conclusion: The choice of tools for evaluating medical education should be guided by the dimension that is targeted by the evaluation. Likewise, evaluation results can only be interpreted within the context of the construct addressed by the data collection tool that was used as well as its specific confounding factors. [ABSTRACT FROM AUTHOR]