Does peer feedback for teaching GPs improve student evaluation of general practice attachments? A pre-post analysis.

Objectives: The extent of university teaching in general practice is increasing and is in part realised with attachments in resident general practices. The selection and quality management of these teaching practices pose challenges for general practice institutes; appropriate instruments are required. The question of the present study is whether the student evaluation of an attachment in previously poorly evaluated practices improves after teaching physicians have received feedback from a colleague. Methods: Students in study years 1, 2, 3 and 5 evaluated their experiences in general practice attachments with two 4-point items (professional competence and recommendation for other students). Particularly poorly evaluated teaching practices were identified. A practising physician with experience in teaching and research conducted a personal feedback of the evaluation results with these (peer feedback), mainly in the form of individual discussions in the practice (peer visit). After this intervention, further attachments took place in these practices. The influence of the intervention (pre/post) on student evaluations was calculated in generalised estimating equations (cluster variable practice). Results: Of 264 teaching practices, 83 had a suboptimal rating. Of these, 27 practices with particularly negative ratings were selected for the intervention, of which 24 got the intervention so far. There were no post-evaluations for 5 of these practices, so that data from 19 practices (n=9 male teaching physicians, n=10 female teaching physicians) were included in the present evaluation. The evaluations of these practices were significantly more positive after the intervention (by n=78 students) than before (by n=82 students): odds ratio 1.20 (95% confidence interval 1.10-1.31; p<.001). Conclusion: The results suggest that university institutes of general practice can improve student evaluation of their teaching practices via individual collegial feedback.

Implementation of online peer feedback for student self-reflection - first steps on the development of a feedback culture at a medical faculty.

Objective: Acquisition and application of professional and personal competences is accompanied by the formation and consolidation of attitudes and values and is influenced by the norms and moods (trust and feedback culture) experienced in the learning environment in question [1]. In particular, feedback and peer feedback can have a positive influence on the learning progress and personal development of students [2], [3], [4]. The promotion of a culture of teaching and ultimately of trust or feedback, plays a special role in this [5]. The aim was therefore to structurally integrate feedback into the curriculum of a model study course in order to develop a feedback culture in which students can develop personally and professionally with the help of regular and constructive feedback. Methodology: Following an initial pilot phase in 2009, (peer) feedback was gradually integrated into the curriculum at the medical faculty, in the first instance through checklists and subsequently through an online questionnaire and direct interviews. The activities were regularly analyzed on the basis of student evaluations using the EvaSys evaluation software and semi-standardized questionnaire-based interviews with six students in 2009 and 13 students each in 2012 and 2013. Results: Initially, students felt that the trust and feedback culture at their location as being in need of improvement. There were uncertainties regarding the use of constructive feedback and making criticism but also trust issues regarding the expression of personal perceptions to faculty members. It was possible to document the increase in the acceptance of the offers in the course of their establishment by an improvement in student evaluation and an increase in the number of participants in the voluntary offers amongst others. Qualitative data showed that students had a more positive perception or assessment of the location's feedback concept as well as indications of improvements in the culture of trust at the location. The proportion of constructive free-text comments increased significantly by 11% to 99.4% compared to the previous year (t(3)=-3.79, p=0.04). Thus, in terms of the objective, an increase in feedback activities and their quality at the faculty was achieved. Conclusion: Feedback, its acceptance as well as the quality, can be positively influenced at a faculty. Change measures should be tested repeatedly in discussion with users regarding practicability in order to directly pick up implementation issues and obstacles so they can be remedied in the interests of the users. This can influence the development of a culture of trust and feedback and should promote the personal and professional development of students in the long term.

Which patients with type 2 diabetes mellitus are perceived as 'difficult' by general practitioners?

AIMS: To find factors that are associated with a general practitioner's (GP's) subjective impression of a patient being 'difficult' within a sample of patients with type 2 diabetes mellitus (T2DM). METHODS: Secondary cross-sectional analysis of a cohort of GP patients with T2DM. GP questionnaire on clinical data and GPs' subjective ratings of patient attributes (including 'patient difficulty'). Patient questionnaire on sociodemographics and illness perceptions. Bivariate and multivariate analyses, adjusted for cluster-effect of GP practice. RESULTS: Data from 314 patients from 49 GPs could be analysed. Independent associations with higher GP-rated difficulty were found for (odds ratio; 95% confidence interval): male patients from male GPs (1.27; 1.06-1.53), unmarried men (1.25; 1.04-1.51), men with non-German nationality (1.80; 1.24-2.61), patients perceiving more problems with diabetes (1.17; 1.04-1.30), patients with higher BMI (1.01; 1.00-1.02) and HbA1c values (1.06; 1.02-1.10), patients being perceived by the GP as less adherent (1.34; 1.22-1.46) and less health-literate (1.19; 1.04-1.35). CONCLUSIONS: The impact of patients' gender and illness perception yield new insights into GP-perceived complexity of care. Culturally and gender-sensitive communication techniques for adapting health care goals to patients' problems (rather than norm values) may alleviate GPs' work.

General practitioners' attitudes towards patients with poorly controlled type 2 diabetes: a qualitative study.

BACKGROUND: Patients with type 2 diabetes mellitus (T2DM) with poor glycaemic control can represent a challenge from the perspective of the general practitioner (GP). Apart from patient-sided factors, the understanding of GPs' attitudes may provide ideas for improved management in these patients. The aim of this study is to reveal attitudes of GPs towards T2DM patients with poor metabolic control. METHODS: Qualitative research in German general practice; 20 GPs, randomly chosen from participants of a larger study; in-depth narrative interviews, audio-recorded and transcribed; inductive coding and categorisation in a multi-professional team; abstraction of major themes in terms of attitudinal responses. RESULTS: 1) Orientation on laboratory parameters: GPs see it as their medical responsibility to achieve targets, which instil a sense of security. 2) Resignation: GPs believe their efforts are in vain and see their role as being undermined. 3) Devaluation of the patient: GPs blame the "non-compliance" of the patients and experience care as a series of conflicts. 4) Fixed role structure: The expert GP on the one hand, the ignorant patient on the other. 5) Solidarity with the patient: GPs appreciate a doctor-patient relationship in terms of partnership. CONCLUSIONS: The conflict GPs experience between their sense of duty and feelings of futility may lead to perceptions such as personal defeat and insecurity. GPs (and patients) may benefit from adjusting the patient-doctor relationship with regard to shared definitions of realistic and authentic goals.

Willingness to participate in mammography screening: a randomized controlled questionnaire study of responses to two patient information leaflets with different factual content.

BACKGROUND: From 2010 onward, a new leaflet about mammography screening for breast cancer, more informative than the preceding version, has been sent to women in Germany aged 50 to 69 with the invitation to undergo screening. The purpose of this study was to determine the effect of different informational content on the decision whether or not to be screened. METHODS: In a randomized and blinded design, 792 women aged 48 to 49 were sent either the old or the new leaflet. Questionnaires were sent together with the leaflets in order to assess the following: willingness to undergo mammography screening, knowledge, decisional confidence, personal experiences of breast cancer, and demographic data. RESULTS: 370 (46.7%) of the questionnaires were returned, and 353 were evaluable. The two groups did not differ significantly in their willingness to be screened: 81.5% (95% confidence interval [CI] 75.8%-87.2%) versus 88.6% (95% CI 83.9%-91.3%, p = 0.060). A post-hoc analysis showed that women who reported having had personal experience of breast cancer (18.7%) were more willing to be screened if they were given the new leaflet, rather than the old one (interaction p = 0.014). The two groups did not differ in their knowledge about screening (p = 0.260). Women who received the old leaflet reported a higher decisional confidence (p = 0.017). The most commonly mentioned factors affecting the decision were experience of breast cancer in relatives and close acquaintances (26.5% of mentions) and a doctor's recommendation (48.2%). Leaflets (3.6%) and all other factors played only a secondary role. CONCLUSION: The greater or lesser informativeness of the leaflet affected neither the participants' knowledge of mammography screening nor their willingness to undergo it. The leaflet was not seen as an aid to decision-making. The best way to assure an informed decision about screening may be for the patient to discuss the matter personally with a qualified professional.

Effects of different information brochures on women's decision-making regarding mammography screening: study protocol for a randomized controlled questionnaire study.

BACKGROUND: In order to give informed consent for mammography screening, women need to be told the relevant facts; however, screening information often remains vague because of the worry that detailed information might deter women from participating in recommended screening programs. Since September 2010, German women aged 50 to 69 invited for mammography screening have received a new, comprehensive information brochure that frankly discusses the potential benefit and harm of mammography screening. In contrast, the brochure that was in use before September 2010 contained little relevant information.The aim of this study is to compare the impact of the two different brochures on the intention of women to undergo mammography screening, and to broaden our understanding of the effect that factual information has on the women's decision-making. METHODS: This is a controlled questionnaire study comparing knowledge, views and hypothetical preferences of women aged 48-49 years after receiving the old versus the new information brochure. German GP's in the region of North Rhine-Westfalia will be asked by mail and telephone to participate in the study. Eligible women will be recruited via their general practitioners (GPs) and randomized to groups A ('new brochure') and B ('old brochure'), with an intended recruitment of 173 participants per group. The study is powered to detect a 15% higher or lower intention to undergo mammography screening in women informed by the new brochure. DISCUSSION: This study will contribute to our understanding of the decision-making of women invited to mammography screening. From both ethical and public health perspectives, it is important to know whether frank, factual information leads to a change in the intention of women to participate in a recommended breast cancer screening program. TRIAL REGISTRATION: DRKS00004271.

Are women getting relevant information about mammography screening for an informed consent: a critical appraisal of information brochures used for screening invitation in Germany, Italy, Spain and France.

BACKGROUND: The aim was to find out if information brochures on mammography screening in Germany, Italy, Spain and France contain more information to facilitate informed consent than in similar studies carried out over the last few years in Sweden, Canada, USA and the UK, countries with different medical cultures. METHODS: We generated a list of essential information items on mammography screening for the purpose of informed consent. We mostly used the same items of information as had been used in previous studies and analysed the information brochures of major national initiatives in Germany and France, and three brochures each from regionalized programmes in Italy and Spain. We cross-checked which of our items were covered in the brochures and if correct numbers were given. RESULTS: We found that the information brochures contained only about half of the information items we defined. Six of the eight brochures mentioned the reduction in breast-cancer fatalities. Four of the eight provided information on false positives, and four of the brochures highlighted the side-effects of radiation. The information on side-effects and risks provided by the brochures was generally of poor quality, and none of them referred to over diagnosis. When numbers were given, they were only indicated in terms of relative numbers. CONCLUSION: The information brochures currently being used in Germany, Italy, Spain and France are no better than the brochures analysed some years ago. Our results suggest that the providers of mammography screening programmes continue to conceal information from women that is essential when making an informed decision.