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[english] Background: The accuracy and reproducibility of medical skills assessment is generally low. Rater training has little or no effect. Our knowledge in this field, however, relies on studies involving video ratings of overall clinical performances. We hypothesised that a rater training focussing on the frame of reference could improve accuracy in grading the curricular assessment of a highly standardised physical head-to-toe examination.Methods: Twenty-one raters assessed the performance of 242 third-year medical students. Eleven raters had been randomly assigned to undergo a brief frame-of-reference training a few days before the assessment. 218 encounters were successfully recorded on video and re-assessed independently by three additional observers. Accuracy was defined as the concordance between the raters' grade and the median of the observers' grade. After the assessment, both students and raters filled in a questionnaire about their views on the assessment.Results: Rater training did not have a measurable influence on accuracy. However, trained raters rated significantly more stringently than untrained raters, and their overall stringency was closer to the stringency of the observers. The questionnaire indicated a higher awareness of the halo effect in the trained raters group. Although the self-assessment of the students mirrored the assessment of the raters in both groups, the students assessed by trained raters felt more discontent with their grade.Conclusions: While training had some marginal effects, it failed to have an impact on the individual accuracy. These results in real-life encounters are consistent with previous studies on rater training using video assessments of clinical performances. The high degree of standardisation in this study was not suitable to harmonize the trained raters’ grading. The data support the notion that the process of appraising medical performance is highly individual. A frame-of-reference training as applied does not effectively adjust the physicians' judgement on medical students in real-live assessments.

[english] Objective: Procedural skills education has a high priority for medical students. However, it is not clear what kind of skills they consider important and whether their perception differs from the physicians’ view.Methods: We conducted a survey on 26 skills in internal medicine among medical students and physicians. Ninety-five fourth year and 62 final year students along with 67 physicians working in medical departments participated in the survey. A similar but smaller survey was completed earlier before the implementation of a skills training at the faculty.Results: Students generally preferred technically complex skills while, in contrast, physicians found “bed-side-skills” more important. The result was independent of the students’ participation in the skills training or of the physicians’ experience. A similar result was achieved in the smaller survey before the implementation of the skills training.Conclusion: Students and physicians significantly differ in their entitlement towards procedural skills education. This should be considered when educational strategies are being discussed.[german] Zielsetzung: Der Wunsch nach praktischer Ausbildung im Medizinstudium wird vor allem von den Studierenden selbst formuliert. Was genau sie sich darunter vorstellen und ob diese Vorstellung mit derjenigen der Ärzte übereinstimmt, ist nicht bekannt. Methodik: Wir führten eine Umfrage zu 26 Fertigkeiten der Inneren Medizin durch, die zuvor unter Studierenden und Ärzten ermittelt worden waren. An der Umfrage nahmen 95 Studierende im vierten Studienjahr, 62 Studierende im Praktischen Jahr und 67 internistisch tätige Ärzte teil. Eine gleichartige, aber kleinere Umfrage hatten wir bereits vor Einführung des Skills-Trainings an unserer Fakultät durchgeführt. Ergebnisse: Während den Studierenden vor allem Fertigkeiten wichtig waren, die hohen technischen Aufwand erfordern, waren das bei den Ärzten eher solche, die mit einfachen Mitteln am Krankenbett ausgeführt werden. Dieses Ergebnis galt unabhängig davon, ob die Studierenden bereits trainiert waren oder nicht, beziehungsweise unabhängig vom Ausbildungsstand der Ärzte. Auch stimmte das Ergebnis der aktuellen Umfrage gut mit derjenigen vor Beginn des Skills-Trainings überein. Schlussfolgerungen: Der Anspruch von Studierenden und Ärzten an die praktische Ausbildung unterscheidet sich grundlegend. Dies sollte bei der Diskussion um Lerninhalte Berücksichtigung finden.

Blood pressure dipping at night is mediated by sleep-inherent, active downregulation of sympathetic vascular tone. Concomitantly, activity of the renin-angiotensin system is reduced, which might contribute to the beneficial effect of baroreflex downward resetting on daytime blood pressure homeostasis. To evaluate whether experimental nondipping mediated by angiotensin II during sleep would alter blood pressure and baroreflex function the next day in healthy humans, angiotensin-II or placebo (saline) was infused for a 7-h period at night, preventing blood pressure dipping in 11 sleeping normotensive individuals (5 males, balanced, crossover design). Baroreflex function was assessed about 1 h upon awakening and stop of infusion via microneurographic recordings of muscle sympathetic nerve activity (MSNA), showing that resting MSNA was significantly increased following angiotensin II nondipping compared with placebo ( P = 0.029), whereas blood pressure and heart rate remained unchanged. Baroreflex sensitivity in response to vasoactive drug challenge was preserved, and neuroendocrine markers of fluid balance and electrolytes did not differ between conditions. Ambulatory blood pressure during subsequent daytime was not altered. Data were compared with analog experiments previously performed within the same subjects during awake daytime (ANCOVA). We conclude that angiotensin-II mediated nocturnal nondipping did not induce blood pressure elevation at subsequent daytime in healthy humans but was linked to increased vasoconstrictive sympathetic activity. This is in contrast to a prolonged increase in blood pressure in corresponding daytime experiments of the same individuals. Evidently, sleep strongly preserves normotensive blood pressure homeostasis in healthy humans.

ANG II interacts with the sympathetic nervous system at central nervous blood pressure-regulating structures, including the baroreflex. It is unknown whether prolonged BP elevation mediated by high ANG II plasma levels could induce a persistent shift of the central nervous baroreflex setpoint, lasting beyond the short ANG II plasmatic half time of a few seconds, thereby consolidating elevated BP and/or increased SNA in healthy humans. In a blinded crossover design, ANG II or placebo (saline) was infused for a 6-h period in 12 resting normotensive students (6 males, 6 females) raising BP to borderline hypertensive levels. Between 60 and 120 min after the infusion period, muscle sympathetic nerve activity (MSNA) was assessed microneurographically and correlated with oscillometric BP measurements and heart rate at supine rest (baseline) and during pharmacologic baroreceptor challenge. Infusion of ANG II increased BP to borderline-hypertensive levels, as intended, whereas heart rate remained unaltered. At baroreflex assessment (i.e., 60-120 min after end of infusion period), systolic BP was significantly higher compared with placebo (Δ8.4 ± 3.1 mmHg; P < 0.05), whereas diastolic values were nearly equal between conditions. Baseline MSNA was neither decreased nor increased, and baroreflex sensitivity to vasoactive drug challenge was not altered. Our results show that elevation of ANG II plasma levels over 6 h was able to increase systolic, but not diastolic, BP far beyond blood-mediated ANG II effects. MSNA or heart rate did not counter-regulate this BP elevation, indicating that ANG II had sustainably reset the central nervous BP threshold of sympathetic baroreflex function to accept elevated BP input signals without counter-regulatory response., (Copyright © 2015 the American Physiological Society.)

Background: Preparing high quality discharge summaries is difficult for first year residents. For 5 years we have been training fourth year students how to write discharge summaries. Our goal is to facilitate the students' start into clinical work. Moreover, we intend to provide the students with a scheme to better memorize patients' histories. Two years after the tutorial the graduates were asked to evaluate the tutorial and to comment on its learning effects., Methods: A total of 1228 fourth year students wrote a discharge summary on a patient in whose care the specific student was involved during his or her training in internal medicine. All summaries were read, commented on and graded by a consultant. Two years after the tutorial 310 graduates were invited to complete an online survey on this tutorial., Results: 106 (34%) of all invited graduates completed the survey. The opinions on the tutorial greatly differed. In principal the students agreed that the tutorial was an important part of medical training and helped to better structure patients' medical data. The majority of the surveyed graduates, however, were not convinced of its practical usefulness for daily work. The students with the poorer grading found their grade less appropriate than the students with the better grading., Conclusions: Though our main goal could not be achieved in the view of the graduates, the overall opinion was rather positive. Problems with this kind of tutorial lay in the enormous effort of correction and in the discouraging effect of grading on the students with difficulties in the task.