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Objective The 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. Methods The 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. Results The 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. Conclusion The initiative and support of all stakeholders, including the dean, teachers and students, were crucial for the project’s success. Practice implications Although 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.

Background: The German national longitudinal communication curriculum provides medical faculties with orientation for the content of their communication teaching. But its implementation also requires changes in the organization of teaching. However, due to a lack of reports and studies on experiences with the development and implementation of communication curricula, recommendations on the procedure and the use of suitable instruments cannot be provided. Consequently, as part of this exploratory study the implementation process of the communication curricula was observed at four faculties. Methods: A comparative case study was conducted against the background of a change management concept. The four participating faculties were selected in such a way that they differed significantly in their initial conditions, particularly the development stage of the communication curriculum. Group interviews were conducted with the project teams at each faculty concerning the conditions and experiences with the implementation process. The evaluation took the form of a qualitative content analysis with a focus on identifying supporting and inhibiting factors and useful activities. Results: Different faculty approaches, support structures, core skills, the scope of study and examination regulations, teaching organization and available resources can have a major impact on the implementation processes. It became clear that, depending on the status of the implementation process, other barriers and supporting conditions gain in importance. Strategically, it proved to be a particular success factor to implement the communication curriculum together with other innovations in the course of the conversion to a model study program. This enabled a particularly quick and efficient implementation. The implementation into an existing curriculum proved to be much more protracted. In addition, a change management concept was used to illustrate which measures were found to be effective for which task areas. This includes, for example, curricular mapping, the development of skills in communication teaching or the integration of communication into exams. Conclusions: Thus a concept with strategies and measures for the implementation of the National Longitudinal Communication Curriculum is available. It already contains numerous suggestions for planning one's own approach in line with the conditions and resources of other locations. However, it needs to be supplemented and further validated., Hintergrund: Das Nationale longitudinale Mustercurriculum Kommunikation gibt medizinischen Fakultäten Orientierung für die inhaltliche Gestaltung ihrer Kommunikationslehre. Zu seiner Umsetzung sind jedoch auch Veränderungen in der Organisation der Lehre erforderlich. Bisher fehlen allerdings Berichte und Untersuchungen zu den Erfahrungen mit der Entwicklung und Implementierung von Kommunikationscurricula, aus denen Empfehlungen zum Vorgehen abgeleitet werden können. Daher wurden im Rahmen dieser explorierenden Untersuchung vier Fakultäten bei der Implementierung ihrer Kommunikationscurricula begleitet. Methoden: Vor dem Hintergrund eines Change-Management-Konzepts wurde eine vergleichende Fallstudie durchgeführt. Die beteiligten vier Fakultäten wurden so ausgewählt, dass sie sich in ihren Ausgangsbedingungen, insbesondere im Entwicklungsstand des Kommunikationscurriculums, deutlich unterschieden. An jeder Fakultät wurden Gruppeninterviews mit den Projektteams zu den Voraussetzungen und den Erfahrungen mit dem Implementierungsprozess durchgeführt. Die Auswertung erfolgte in Form einer qualitativen Inhaltsanalyse zur Identifikation unterstützender und hemmender Einflussfaktoren und zielführender Aktivitäten. Ergebnisse: Einstellungen an der Fakultät, Unterstützung, Kompetenzen, der Spielraum der Studien- und Prüfungsordnungen, die Lehrorganisation und die verfügbaren Ressourcen können großen Einfluss auf Implementierungsprozesse nehmen. Deutlich wurde, dass je nach Stand im Implementierungsprozess andere Barrieren und unterstützende Bedingungen im Vordergrund stehen. Strategisch erwies es sich als ein besonderer Erfolgsfaktor, das Kommunikationscurriculum im Zuge der Umstellung auf einen Modellstudiengang gemeinsam mit anderen Innovationen umzusetzen. Dadurch war eine besonders rasche und effiziente Umsetzung möglich. Die Implementierung in ein bestehendes Curriculum erwies sich als deutlich langwieriger. Zusätzlich wurde anhand eines Change-Management-Konzepts abgebildet, für welche Aufgabenfelder welche Maßnahmen als zielführend befunden wurden. Dazu gehört etwa das Curricular Mapping, die Entwicklung von Kompetenzen zur Kommunikationslehre oder die Integration von Kommunikation in die Prüfungen. Schlussfolgerungen: Somit liegt ein Konzept mit Strategien und Maßnahmen zur Implementierung des Nationalen longitudinalen Kommunikationscurriculums vor. Es enthält bereits jetzt zahlreiche Anregungen zur Planung des eigenen Vorgehens passend zu den Gegebenheiten und Ressourcen anderer Standorte. Allerdings bedarf es der Ergänzung und weiteren Validierung., GMS Journal for Medical Education; 38(3):Doc52

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.

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.

The care for patients with advanced disease and limited prognosis and their relatives is complex and characterized by insufficient communication and lack of coordination and continuity.Development of an interprofessional, practice-guided concept of longitudinally structured communication with the goal of fostering communication, improving quality of life and facilitating early integration of palliative care.Multi-level process starting from a draft with discussion and approval within the multiprofessional team and correlation with interviews with patients and relatives. Preparation of a comprehensive concept with review of the literature, problem analysis, theoretical foundation, goal setting and intervention components. Discussion of suitability for daily use, adaptation and further development of the concept.Concept with the following components: interprofessional communication training, structured conversations at defined moments in a tandem of physician and nurse with patient and relative, follow-up conversations conducted by the nurse, and respective instruments (conversation protocol, question prompt list, memory cards). Only iterative discussion with and the approval of patients, relatives and the multiprofessional team and their approval will put the concept into practice.

Background The care needs of patients with a limited prognosis (

Objective Type D personality, as with formal mental disorders, is linked to increased mortality in coronary heart disease (CHD). Our aim was to determine the prevalence of mental disorders among depressed CHD patients with and without Type D personality. Methods Depressive symptoms (HADS, HAM-D), Type D personality (DS-14) and mental disorders based on DSM-IV (SCID I and II) were assessed. Results were calculated by Kruskal-Wallis tests, Fisher's exact tests and logistic regression analyses. Results 570 CHD patients were included (age 59.2 ± 9.5 years; male 78.9%, HADS-D depression 10.4 ± 2.5; HAM-D 11.3 ± 6.6; Type D 60.1%). 84.8% of patients with Type D personality and 79.3% of non-Type D patients suffered from at least one mental disorder (p = 0.092), while 41.8% of Type D positives and 27.8% of Type D negatives had at least two mental disorders (p = 0.001). Patients with Type D personality significantly more often had social phobia [odds ratio (95% confidence interval): 3.79 (1.1 to 13.12); p = 0.035], dysthymia [1.78 (1.12 to 2.84); p = 0.015], compulsive [2.25 (1.04 to 4.86); p = 0.038] or avoidant [8.95 (2.08 to 38.49); p = 0.003] personality disorder. Conclusions Type D personality among depressed CHD patients is associated with more complex and enduring mental disorders. This implies higher treatment demands. Trial registration ISRCTN 76240576; NCT00705965

In Germany, future physicians have to pass a national licensing examination at the end of their medical studies. Passing this examination is the requirement for the license to practice medicine. The Masterplan Medizinstudium 2020 with its 41 measures aims to shift the paradigm in medical education and medical licensing examinations.The main goals of the Masterplan include the development towards competency-based and practical medical education and examination as well as the strengthening of general medicine. The healthcare policy takes into account social developments, which are very important for the medical education and licensing examination.Seven measures of the Masterplan relate to the realignment of the licensing examinations. Their function to drive learning should better support students in achieving the study goal defined in the German Medical Licensure Act: to educate a medical doctor scientifically and practically who is qualified for autonomous and independent professional practice, postgraduate education and continuous training.

In 2012 the German medical licensure regulations (Approbationsordnung) made teaching and assessing the conduction of medical consultations a mandatory part of medical education. A catalogue of learning objectives (LO) based on existing references was developed to assist medical schools in meeting this requirement.A body of relevant material was compiled using literature research and surveying experts. Then, in a multiphase Delphi process, this was evaluated and condensed by an interdisciplinary working group in dialogue with external (clinical) experts. Competence levels and examples of clinical application were assigned to enhance implementation. The catalogue was revised by the medical faculties, professional associations and the BVMD.This learning catalogue comprised 116 learning objectives for the specific skills necessary to conducting medical consultations as well as exemplary application contexts. The catalogue proved to be practical in terms of developing curricula and networking at medical schools.This catalogue of learning objectives can serve as the basis for developing a sample communication curriculum for use by medical faculties.

Medical education in Germany has undergone significant changes. The current article attempts to give an overview of final year medical education in Germany and implications for further developments. Challenges in final year medical education mainly arise from the lack of clearly defined learning objectives, the provision of structure, independent patient management and professional guidance and supervision. The abolition of the one-and-a-half-year period of pre-registration medical training in 2004 and the changes in the structure of state examinations in line with the amendment of medical licensing regulations in 2002, meant pressure on the efficiency of final year medical education on the one hand, and additional burden on final year students on the other. In this article, a broad variety of innovative models that have been implemented at different medical faculties, and which address final year students' needs, will be reported. Further challenges, such as the integration of general medicine rotations, the abolishment of the second state examination in its present form, and the integration of final year students' individual career plans will be discussed.

Peer-assisted learning (PAL) has become a well-accepted teaching method within medical education. However, descriptions of on-ward PAL programmes are rare. We introduced a PAL programme with a focus on clinical competencies on internal medicine wards.To assess the effects of an on-ward PAL programme on self-assessed clinical competencies.A total of 168 medical students were randomly assigned to one of the seven intervention wards or one of the seven control wards. During their 5-week ward-placement, the intervention group (IG; n = 88) received 10 patient-centred tutorials lead by final year tutors: (I) history taking, (II) physical examination, (III) blood withdrawal, (IV) infusion, (V) patient files, (VI and VII) ECG, (VIII-X) chart rounds. The control group (CG; n = 80) did not take part in the PAL programme. Clinical competencies were self-assessed pre- and post-intervention.For five of the ten assessed clinical competencies, increases in self-confidence ratings were significantly higher in the IG as compared to CG.RESULTS provide preliminary evidence to suggest that PAL programmes on internal medicine wards and with final year students as peer tutors may represent a valuable additional tool within medical clerkships. However, the findings must be confirmed and clarified in further research.

Following the changes made to the medical licensing regulations of 2002, medical education in Germany has been subject to radical modification, especially at undergraduate level. The implementation of the Bologna Process is still a matter of intense political debate, whilst positive movement has occurred in developing the professionalisation of teaching staff through a Masters Degree in Medical Education. In the area of postgraduate medical education, major restructuring of programmes is occurring, whilst the debate in continuing medical education is related to the amount of practical clinical education that is required.

Background: The final year of medical education is considered crucial in making students ‘fit for purpose’. Studies have shown that many students leave medical school without having experienced sufficient preparation for their upcoming professional life. Aim: The aim of this study was to examine the effectiveness of a supplementary internal medicine final year curriculum on clinical reasoning skills. Method: Final year internal medicine students from two universities participated in the study which was based on a static-group design. The experimental group (n ¼ 49) took part in a final year student curriculum with interactive case-based seminars and skills training sessions. The comparison group (n ¼ 25) did not receive any additional training beyond working on the ward. Clinical reasoning skills were assessed using a key-feature pre-post test. Results: Prior to their clinical rotation, the two groups did not differ in the key-feature examination ( p50.924). The experimental group performed significantly better than the comparison group ( p50.028) in the post-intervention key-feature examination. Conclusions: Supplementary interactive case-based seminars and skills training sessions are effective and significantly improve the clinical reasoning skills of final year students in internal medicine. Further study is warranted and should look to examine the effectiveness of a final year student curriculum on other performance measures.

Recently, efforts have been undertaken to enhance the face validity of technical skills training by introducing role-plays and standardised patients. Since little is known about the effects of role-playing with respect to the realism of a training situation and students' objective performance, we performed a randomized controlled trial.36 medical students participated in videotaped small group skills-lab sessions on the topics of Doppler sonography and gastric tube insertion. One half of the students participated in role-plays and the other half practised without role-playing. Realism of the training situation was analysed by means of post-intervention self-selected student survey evaluations. Technical performance and patient-physician communication were assessed by independent ratings of the videotaped sessions.The physician's role was regarded to be significantly more realistic when performing role-plays. Assessment of videotaped sessions showed that practising technical skills by performing role-plays resulted in significantly better patient-physician communication whereas students' technical performance did not differ between groups.Introducing role-plays enhances the realism of technical skills training and leads to better patient-physician communication. Students do not seem to be overstrained by practising clinical technical skills using role-plays. We conclude that role-playing is a valuable method in practising technical skills.

The "National Competency-Based Catalogue of Learning Objectives for Medicine" ("Nationaler Kompetenzbasierter Lernzielkatalog Medizin,"NKLM) is a core curriculum developed for medical training. Here, the classic division by discipline and organ system has been abandoned, which requires each discipline to define its own core curriculum in specific catalogues of learning objectives. This article presents such a catalogue for Psychosomatic Medicine and Psychotherapy.A two-step DELPHI-method was used to survey faculty representatives for Psychosomatic Medicine and Psychotherapy. It reflected the discipline-specific university catalogues of learning objectives as well as the NKLM. A catalogue of learning objectives was then developed and approved.The catalogue consists of two parts: (1) a 12-module core curriculum for Psychosomatic Medicine and Psychotherapy and (2) selected interdisciplinary learning objectives from the NKLM with relevant participation of the discipline in ten modules.For the first time in Germany, this article presents a catalogue of learning objectives for Psychosomatic Medicine and Psychotherapy that is agreed upon by the relevant representatives. This enables the integration of psychosomatic and psychotherapeutic teaching contents from a department into the overall curriculum as required by the NKLM. In the future, methods should be established to allow regular updating and further development of this catalogue.

At the Faculty of Medicine in Heidelberg, implementation of an interdisciplinary longitudinal curriculum was started in 2001 with the goal of achieving sustained promotion of communicative and clinical competences. The aim of this paper is to describe the development and implementation of Heidelberg's longitudinal communication curriculum. Furthermore, innovative aspects and strategies are discussed. The methodological approaches for development and implementation were Kern's "Six-step Approach" and a SWOT analysis. The process resulted in an innovative communication curriculum that starts with an integrated curriculum for developing clinical and communicative competence in the pre-clinical phase and continues in the clinical phase with medical communication and interactive training. Satisfaction with the communication curriculum and its effectiveness were rated highly by students. Residents who had graduated from Faculty of Medicine in Heidelberg rated the extent to which they had communicative competencies at the time of their graduation at their disposal significantly higher than residents who had graduated from the other 4 medical faculties in Baden-Württemberg. The experiences gained in Heidelberg can be applied by other faculties.

SUMMARY The purpose of our study was the development and validation of a modified electronic key feature exam of clinical decision-making skills for undergraduate medical students. Therefore, the reliability of the test (15 items), the item difficulty level, the item-total correlations and correlations to other measures of knowledge (40 item MC-test and 580 items of German MC-National Licensing Exam, Part II) were calculated. Based on the guidelines provided by the Medical Council of Canada, a modified electronic key feature exam for internal medicine consisting of 15 key features (KFs) was developed for fifth year German medical students. Long menu (LM) and short menu (SM) question formats were used. Acceptance was assessed through a questionnaire. Thirty-seven students from four medical schools voluntarily participated in the study. The reliability of the key feature exam was 0.65 (Cronbach’s alpha). The items’ difficulty level scores were between 0.3 and 0.8 and the item-total correlations between 0.0 and 0.4. Correlations between the results of the KF exam and the other measures of knowledge were intermediate (r between 0.44 and 0.47) as well as the learners’ level of acceptance. The modified electronic KF examination is a feasible and reliable evaluation tool that may be implemented for the assessment of clinical undergraduate training.

SUMMARY Clinical skills are an important and necessary part of clinical competence. Simulation plays an important role in many fields of medical education. Although role-playing is common in communication training, there are no reports about the use of student role-plays in the training of technical clinical skills. This article describes an educational intervention with analysis of pre- and postintervention self-selected student survey evaluations. After one term of skills training, a thorough evaluation showed that the skills-lab training did not seem very realistic nor was it very demanding for trainees. To create a more realistic training situation and to enhance students’ involvement, case studies and role-plays with defined roles for students (i.e. intern, senior consultant) were introduced into half of the sessions. Results of the evaluation in the second term showed that sessions with role-playing were rated significantly higher than sessions without role-playing.

Summary Background The physical examination of patients is an important diagnostic competence, but little is known about the examination skills of final-year medical students. Aims To investigate physical examination skills of final-year medical students. Methods In a cross-sectional study, 40 final-year students were asked to perform a detailed physical examination on standardized patients. Their performances were video-recorded and rated by independent video assessors. Results Video ratings showed a mean success rate of 40.1 % (SD 8.2). As regards accompanying doctor-patient communication, final-year students achieved a mean of no more than 36.7 % (SD 8.9) in the appropriate use of the corresponding communication items. Conclusions Our study revealed severe deficits among final-year medical students in performing a detailed physical examination on a standardized patient. Thus, physical examination skills training should aim to improve these deficits while also paying attention to communicative aspects.

Background: Learning on the ward as a practice-oriented preparation for the future workplace plays a crucial role in the medical education of future physicians. However, students’ ward internship is partially problematic due to condensed workflows on the ward and the high workload of supervising physicians. For the first time in a German-speaking setting, students’ expectations and concerns about their internship on the ward are examined in a qualitative analysis regarding their internal medicine rotation within clinical medical education. Methods: Of a total of 168 medical students in their 6th semester at the Medical Faculty of Heidelberg, 28 students (m=8, f=20, Ø 23.6 years) took part in focus group interviews 3 to 5 days prior to their internship on the internal medicine ward within their clinical internal medicine rotation. Students were divided into four different focus groups. The protocols were transcribed and a content analysis was conducted based on grounded theory. Results: We gathered a total of 489 relevant individual statements. The students hope for a successful integration within the ward team, reliable and supportive supervisors and supervision in small groups. They expect to face the most common diseases, to train the most important medical skills, to assume full responsibility for their own patients and to acquire their own medical identity. The students fear an insufficient time frame to achieve their aims. They are also concerned they will have too little contact with patients and inadequate supervision. Conclusion: For the development and standardization of effective student internships, the greatest relevance should be attributed to guidance and supervision by professionally trained and well-prepared medical teachers, entailing a significant increase in staff and costs. A structural framework is required in order to transfer the responsibility for the treatment of patients to the students at an early stage in medical education and in a longitudinal manner. The data suggest that the development and establishment of guidelines for medical teachers associated with clearly defined learning objectives for the students’ internships are urgently needed. Based on our findings, we provide first recommendations and suggest possible solutions.

Summary Background: Health-related quality of life (HRQOL) following orthotopic liver transplantation (OLT) has become increasingly important. Therefore, we aimed to identify factors affecting HRQOL after OLT. Material/Methods: This cross-sectional, single-centre study surveyed 281 OLT patients. Survey tools included the Short Form (SF-36) Health Survey, the Patient Health Questionnaire 9 (PHQ9), and a self-designed employment questionnaire. Patient medical records were reviewed. Results: Participants included 187 men (mean age at OLT: 50 [±11; 13–69] years). Primary indications for OLT were viral hepatitis (28%), alcoholic liver disease (35%), cholestatic liver disease (11%), and others (26%). Follow-up ranged from 2 to 136 months. Clinical factors associated with improved HRQOL were age ≤45 years at OLT and current MELD score

Aim: Student tutorials are now firmly anchored in medical education. However, to date there have only been isolated efforts to establish structured teacher training for peer tutors in medicine. To close this gap, a centralized tutor training program for students, culminating in an academic certificate, was implemented at Heidelberg University Medical School. The program also counts within the scope of the post-graduate Baden-Württemberg Certificate in Academic Teaching (Baden-Württemberg Zertifikat für Hochschuldidaktik). Method: Based on a needs assessment, a modular program comprised of four modules and a total of 200 curricular units was developed in cooperation with the Department for Key Competencies and Higher Education at Heidelberg University and implemented during the 2010 summer semester. This program covers not only topic-specific training sessions, but also independent teaching and an integrated evaluation of the learning process that is communicated to the graduates in the form of structured feedback. In addition, to evaluate the overall concept, semi-structured interviews (N=18) were conducted with the program graduates. Results: To date, 495 tutors have been trained in the basic module on teaching medicine, which is rated with a mean overall grade of 1.7 (SW: 0.6) and has served as Module I of the program since 2010. A total of 17% (N=83) of these tutors have gone on to enroll in the subsequent training modules of the program; 27 of them (m=12, f=15) have already successfully completed them. Based on qualitative analyses, it is evident that the training program certificate and its applicability toward the advanced teacher training for university instructors pose a major incentive for the graduates. For successful program realization, central coordination, extensive coordination within the medical school, and the evaluation of the attained skills have proven to be of particular importance. Conclusion: The training program contributes sustainably to both quality assurance and professionalism, as well as to solving the issue of resources in medical education. The introduction and continued development of similar programs is desirable.

Empathy is a central element in daily patient care. The burnout syndrome seems to be a potential factor influencing physicians' empathic behavior negatively. In Germany up to 20 % of practicing physicians experience burnout. So far, there have been no studies measuring empathy and the degree of burnout among final-year medical students in Germany. The aim of the current study was to investigate final-year students' self-reported empathy, burnout and the association of job satisfaction and occupational self-efficacy with regard to potential gender differences.127 medical students at the end of their final year (82 f, 45 m; 26.8 years of age) were surveyed using the Jefferson Scale of Physician Empathy (JSPE), the Maslach Burnout Inventory (MBI) and items addressing job satisfaction and occupational self-efficacy.The mean JSPE score of all final-year students was 113.25 ± 10.21 (20=lowest possible empathy score, 140=highest possible empathy score). Based on the three dimensions of burnout, the students fell in the moderate burnout category in all subscales of the MBI. There was an association between a lower empathy score and a higher burnout score. Also, the MBI correlated negatively with final-year students' job satisfaction and occupational self-efficacy.Despite high self-rated empathy scores, the experience of burnout symptoms in medical students may begin as early as their final year of studies, where higher levels of burnout are associated with lower self-rated empathy scores. The number of final-year medical students affected by clinically significant burnout (up to 20 %) was just as high as among practicing physicians. Female students were found to be particularly affected. Given the rising numbers of female graduates, this shows that urgent action is required.

Aims: In most German medical faculties, credits in general practice can be earned via exams using multiple-choice questions (MCQ). Measures such as peer-reviews may help assure the quality of these exams. In order to use time and personnel intensive peer reviews effectively and efficiently, the procedures used are key. Therefore, we wanted to find out whether there are differences between group and individual reviews regarding defined parameters. Methods: We conducted a controlled cross-over study with three GP reviewers from four different German universities. Each reviewed 80 MCQs, 40 individually and 40 within a group, including external assessments by a panel of experts. Furthermore all reviewers were asked to evaluate the review process and the time spent carrying out these reviews. Outcomes: We found no significant differences between the reliability and the validity of individual reviews versus group reviews. On average slightly more time was spent on group reviews compared with the individual reviews. The subjective assessments of the study participants regarding their satisfaction with the process and the efficiency and effectiveness of the reviews suggest a preference for group reviews. Conclusions: Based on this study, there are no definite recommendations for or against either approach. When choosing between the two, the specific work structures and organisation at the local faculty should be taken into account.

The implementation of the amendment to the German medical licensing regulations ("Approbationsordnung") in 2002 led to a reduction in the number of state examinations from four to two exams, with the date of the second state exam being shifted to the end of the final clinical year. Students now face a double burden: on the one hand, they need to get ready for their future job, and on the other hand, they need to prepare for the state exam. This is why the Medical Faculty of Heidelberg introduced a preparation programme for the second state exam. The focus of this study was to evaluate the acceptance of the different modules of this programme and to compare the results against each other.39 students (15 male / 24 female; mean age 26.6 ± 1.9 years) took part in the exam preparation programme at the Medical University Hospital Heidelberg. Five different modules were implemented: an informational meeting, a key-feature written exam, case-based multiple-choice exams, a simulated practical examination and a simulated oral examination. Acceptance was measured using a six-point Likert scale (1=very good, 6=unsatisfactory and 1=I completely agree, 6=I completely disagree, respectively)The exam preparation programme as a whole was rated good: overall rating key-feature written exam 3.33 ± 1.17; case-based multiple-choice exams 2.61 ± 1.61; simulated practical exam 1.61 ± 0.54; simulated oral exam 1.55 ± 0.50. A comparison of the different modules demonstrated significantly better ratings for the practical and oral examinations than the case-based multiple-choice exams (p0.001).The presented exam preparation programme is well accepted and facilitates the preparation for the second state exam, particularly with regard to the oral-practical examination.

Background To assess the student perspective on acceptability, realism, and perceived effect of communication training with peer role play (RP) and standardised patients (SP). Methods 69 prefinal year students from a large German medical faculty were randomly assigned to one of two groups receiving communication training with RP (N = 34) or SP (N = 35) in the course of their paediatric rotation. In both groups, training addressed major medical and communication problems encountered in the exploration and counselling of parents of sick children. Acceptability and realism of the training as well as perceived effects and applicability for future parent-physician encounters were assessed using six-point Likert scales. Results Both forms of training were highly accepted (RP 5.32 ± .41, SP 5.51 ± .44, n.s.; 6 = very good, 1 = very poor) and perceived to be highly realistic (RP 5.60 ± .38, SP 5.53 ± .36, n.s.; 6 = highly realistic, 1 = unrealistic). Regarding perceived effects, participation was seen to be significantly more worthwhile in the SP group (RP 5.17 ± .37, SP 5.50 ± .43; p < .003; 6 = totally agree, 1 = don't agree at all). Both training methods were perceived as useful for training communication skills (RP 5.01 ± .68, SP 5.34 ± .47; 6 = totally agree; 1 = don't agree at all) and were considered to be moderately applicable for future parent-physician encounters (RP 4.29 ± 1.08, SP 5.00 ± .89; 6 = well prepared, 1 = unprepared), with usefulness and applicability both being rated higher in the SP group (p < .032 and p < .009). Conclusions RP and SP represent comparably valuable tools for the training of specific communication skills from the student perspective. Both provide highly realistic training scenarios and warrant inclusion in medical curricula. Given the expense of SP, deciding which method to employ should be carefully weighed up. From the perspective of the students in our study, SP were seen as a more useful and more applicable tool than RP. We discuss the potential of RP to foster a greater empathic appreciation of the patient perspective.

Objectives: A clinical practice guideline (CPG) contains specifically developed recommendations that can serve physicians as a decision aid in evidence-based practice. The implementation of heart failure (HF) CPGs represents a challenge in general practice. As part of the development of a tailored curriculum, aim of this study was to identify barriers of guideline adherence and needs for medical education (CME) in HF care. Methods: We conducted a modified focus group with elements of a workshop of three hours duration. Thirteen GPs collected and discussed together and parallel in smaller groups barriers of guideline implementation. Afterwards they performed a needs assessment for a tailored CME curriculum for chronic HF. The content of the discussions was analysed qualitatively according to Mayring and categorised thematically. Results: Barriers of guideline adherence were found in the following areas: doctor: procedural knowledge (knowledge gaps), communicative and organisational skills (e.g. time management) and attitude (dissatisfaction with time-money-relation). Patients: individual case-related problems (multimorbidity, psychiatric comorbidity, expectations and beliefs). Doctor and patient: Adherence and barriers of communication. Main measures for improvement of care concerned the areas of the identified barriers of guideline adherence with the focus on application-oriented training of the abovementioned procedural knowledge and skills, but also the supply of tools (like patient information leaflets) and patient education. Conclusion: For a CME-curriculum for HF tailored to the needs of GPs, a comprehensive educational approach seems necessary. It should be broad-based and include elements of knowledge and skills to be addressed and trained case-related. Additional elements should include support in the implementation of organisational processes in the practice and patient education.

Objective Although psychiatric comorbidity often goes undetected and untreated in cardiovascular patients, it is not clear whether the costs for a special treatment of psychiatric comorbidity are appropriately reflected in the reimbursement system. To investigate the economic impact of psychiatric comorbidity, we compared costs, returns, net gain, and duration of hospitalization in cardiovascular inpatients with and without psychiatric comorbidity. Methods For a period of 2 years, we analyzed costs, net gain, and other outcome variables according to the diagnosis-related group (DRG) system for cardiovascular inpatients of a German university department ( n =940). Psychiatric disorders were diagnosed by the treating physicians based on clinical criteria and results from the Patient Health Questionnaire (PHQ). With respect to the outcome variables, we compared patients with and without a psychiatric disorder, controlling for sociodemographic characteristics. Results The average total costs of hospitalization (mean±S.E.) for cardiovascular patients without psychiatric comorbidity and for patients with psychiatric comorbidity differed significantly (€5142±210 vs. €7663±571; d =0.39). The increased costs for patients with psychiatric comorbidity were related to elevated returns, but the net gain for patients without psychiatric comorbidity was €277±119. In contrast, the treatment of internal medicine patients with psychiatric disorders resulted in a net loss of −€624±324 (overall group difference, d =−0.25). Conclusion Psychiatric comorbidity in cardiovascular inpatients leads to higher costs that are not reflected in the current reimbursement system in Germany. The inappropriate reimbursement of psychiatric comorbidity in cardiovascular inpatients may result in a serious undertreatment of these patients.

The amended German license to practice medicine (AAppO) focuses on practically oriented, patient-centred medical education. After the cancellation of the former medical doctor traineeship "Arzt im Praktikum" (AiP) qualification period in October 2004, the final year of medical education, the so-called "practical year" (PJ), has become a key teaching module in realising the demands of the AAppO. So far no studies have been carried out in the German-speaking area to qualitatively assess the specific needs and central problems that PJ students are facing. The aim of this investigation was to representatively evaluate the expectancies and experiences of final-year medical students in a workplace learning environment.65 students (30 male, 35 female, age 25.4 +/- 2 years) of two German university hospitals participated in focus groups both prior and subsequent (n = 60; drop-out rate 7.7%) to a 4-month period of internal medicine traineeship during their final year. Focus group protocols were transcribed and subjected to content analysis.1137 individual statements on relevant topics were identified from the transcriptions. Students widely reported lack of time on the part of supervising doctors and exorbitant assignment to routine jobs. This results in insufficient training of independent patient management, followed by feelings of uncertainty and the fear of making medical errors.Specific educational strategies and motivation of medical teachers are important factors to the workplace learning environment. A structured curriculum including cognitive, procedural and communicative learning objectives and the introduction of defined time slots for bedside teaching is considered a good first step in this process.

Quality management of assessment in medical education plays a key role in Germany--owing to, among other factors, the new medical licensing regulations ("Approbationsordnung"). OSCE (Objective Structured Clinical Examination) is a widespread tool to assess clinical competencies. However, the quality of OSCE in terms of reliability as a criterion of a good test is highly debated in the current literature. To improve the reliability of the OSCE three accompanying measures have been implemented at the Faculty of Medicine of the University of Heidelberg since the summer of 2006: 1. the application of a checklist for pre- and post-reviews of OSCEs, 2. a specific training of OSCE examiners, 3. an advanced psychometric OSCE test report giving feedback to the item developer. The reliability of the Internal Medicine OSCE at the University of Heidelberg has increased since. Currently Cronbach's alpha of the final OSCE in the summer of 2007 was 0.829.

The implementation of new medical licensing regulations (AAppO 2003) was the starting point for radical curricular changes in all German medical schools. In 2004, the postgraduate and interfaculty Master of Medical Education (MME) degree programme was established at the University of Heidelberg under the auspices of the Medical Faculty Association (Medizinischer Fakultätentag, MFT) and supported by the Association for the Promotion of Science and Humanities in Germany (Stifterverband für die Deutsche Wissenschaft). This new degree programme is intended to train multipliers and leaders in medical education, to build a German-speaking network and to strengthen educational research. The eight one-week MME modules are organised by seven locations in Germany (Munich, Tuebingen, Muenster/Essen, Berlin, Heidelberg, Cologne, Dresden) and an annually changing international faculty. The instructor teams are composed of national and international experts. Major focal points include: curriculum development, education theory, teaching and exam methods, evaluations, team building and group dynamics, project management, leadership, and faculty development, as well as educational research. The modules are connected with each other longitudinally: each participant conducts a project to improve teaching in his or her own faculty and writes a master's thesis about an educational research project. Overall, the participants earn 60 ECTS (European Credit Transfer System) in the course of two years while working. So far 100 participants (25 per year) from 33 of 34 medical faculties have started the program and 19 participants (50% of the participants from Cohort 1, 29% of the participants from Cohort 2) completed the program. The evaluation of the individual modules showed a very high level of participant satisfaction. In two modules, the evaluation results demonstrated a need for change. In 2006, an external evaluation conducted by international experts positively highlighted the MME Programme structure as a leading example emphasizing all aspects of modern medical education, including relevant managerial skills. The MME Programme as a contribution to the professionalization of medical education in the German-speaking area has become firmly established. The impact of the MME Programme on the career development of its participants and the institutional development of the medical faculties still remains to be evaluated.

BACKGROUND: Although chronic heart failure (CHF) is often complicated by comorbid depression and poor self-care, little is known about their specific association in patients with CHF. OBJECTIVE: To investigate self-care behavior among patients with CHF with different degrees of depression severity. METHODS: A total of 287 patients with documented CHF, New York Heart Association functional class II to IV, completed the European Heart Failure Self-Care Behavior Scale. The Structured Clinical Interview for DSM (SCID) IV served as the criterion standard for the presence of a depressive disorder. RESULTS: Analyses of covariance and linear regression analyses revealed that patients with CHF with minor depression reported significantly lower levels of self-care than patients with major depression (P .003) and nondepressed patients (P .014). In addition to minor depression, age (P .001), multimorbidity (P .01), left ventricular ejection fraction (P .001), and family status (P .01) were determinants of self-care. CONCLUSION: Our results demonstrate that patients with CHF with minor depression and not major depression are at higher risk for poor self-care and its resulting consequences, such as symptom deterioration and frequent hospitalization. (Heart Lung® 2009;38:392–397.)

Following the recent amendment to the Medical Education Act in Germany (Approbationsordnung 2002) and the abolition of the preliminary approbation for early residency (AiP), the discussion increasingly focuses on the restructuring of German post-graduate medical training. The training should include well-defined learning objectives and an educational concept with a central emphasis on communication skills training. In the German-speaking countries there has as yet been no publication of a structured training course for the improvement of communication skills in the context of post-graduate education.Jointly designed by the University of Heidelberg's Clinic of Internal Medicine and Clinic of Paediatrics, this study aimed to measure the effect of a training programme for handling problems and difficult situations arising in the communication with parents and patients. 28 paediatric residents took part in a randomised controlled trial using standardized patients and video-feedback (intervention group: N = 14; control group: N = 14). Upon completion of the study, the control group also received training and was subsequently evaluated. The training course consisted of four units, lasting 90 minutes each. Both the acceptance of the training units and the self-evaluation of communication skills in dealing with parents were subject to assessment.The participating residents acknowledged the training course to be an extremely useful tool for improving their communication skills and confidence in dealing with the parents of ill children. A pre-post comparison of self-assessed communication skills revealed a significant increase in the intervention group, but not in the control group.The structured training course presented in the current study proved highly effective and should serve as a model for a compulsory component of a post-graduate training.

Integrating medical students into their future working environment is of utmost importance in order to ensure a smooth transition from university life to clinical practice. In the German-speaking area, there has so far been no quantitative analysis of the extent or the quality of supervision received by medical students during their ward clerkship during their clinical studies in the specialist field of internal medicine.In the summer of 2005, 161 medical students in their 6th and 7th semester undertook ward clerkships on internal wards at the University Clinic of Heidelberg and its academic hospitals. Using a questionnaire, a survey was conducted among these students about the intensity and quality of supervision received during their work on ward.Medical students working on the wards of academic hospitals were significantly more frequently co-supervised by senior physicians (p0.001), while a higher level of co-supervision by final year students was reported for the University Clinic (p0.001). Students supervised by final year students reported greater subjective learning outcomes (p0.001). However, this had no effect on the extent to which students felt integrated on the ward.Final year students play a central role in incorporating medical students into the ward routines of teaching hospitals. While they cannot replace instruction or supervision by a qualified physician, the promising potential of "peer-teaching" programmes should be utilized and junior physicians should be systematically prepared for and supervised in this important function.

Ward rounds are an essential activity for doctors in hospital settings and represent complex tasks requiring not only medical knowledge but also communication skills, clinical technical skills, patient management skills and team-work skills. The present study aimed to identify final year students' deficiencies in conducting ward rounds in order to aid the development of appropriate teaching tools.45 final year students participated in a simulated ward round session with three standardised patient scenarios: (1) myocardial infarction, (2) poorly controlled diabetes, and (3) acute fever in acute myeloid leukaemia. Videotaped sessions were rated by independent raters using binary item checklists which reflected predefined learning goals in five different domains: (I) information gathering, (II) communication with patient, (III) focused physical examination, (IV) chart reviewing/ prescription/ documentation and (V) team communication.For the three patient scenarios, 64.3% of the domain-specific learning goals were attained for the domain "information gathering", 79.4% for "communication with patient", 62.6% for "focused physical examination", 48.9% for "chart reviewing/ prescription/ documentation" and 86.0% for the domain "team communication".Final year students' ward round skills appear to be insufficient with a central deficit in reviewing charts and initiating appropriate prescriptions and documentation. Ward round training which eases the transition from observing ward rounds to conducting them on one's own is urgently required.