[Body image and psychiatric comorbidity in patients with somatoform gastrointestinal disorders]. / Körperbild und psychische Komorbidität bei Patienten mit somatoformen autonomen Funktionsstörungen des oberen und unteren Gastrointestinaltrakts.

OBJECTIVES: The significance of body perception and satisfaction with one's own body in patients with somatoform disorders of the upper and lower gastrointestinal tract is presently unknown, as is the relationship thereof to depression and other psychiatric comorbidities. METHODS: Consecutive patients from the outpatient clinic of a university centre presenting with symptoms suggestive of somatoform gastrointestinal disorders were examined by gastroenterological and psychosomatic experts. In addition, psychological tests (The Body Image Questionnaire, FKB-20, the Hospital Anxiety and Depression Scale, HADS-D) were carried out. RESULTS: Complete data from n = 44 patients were evaluated. In 64 % of patients we found high scores of anxiety, and in 45 % high scores of depression. In the FKB-20, 32 % of patients scored high on the "Negative Evaluation of the Body" subscale (AKB), and 96 % had low scores on the subscale "Perception of Body Dynamics" (VKD). Patients with functional bowel disorders perceived their own body significantly more negative than did healthy controls and patients after acute myocardial infarction. The AKB subscale of the FKB-20 correlated significantly and positively with anxiety in the HADS. HADS depression in turn correlated negatively with the VKD subscale of the FKB-20: Patients with low scores in depression report higher vitality. CONCLUSIONS: Nearly half of the patients with somatoform gastrointestinal disorders seen at a university centre exhibited high scores in anxiety and depression. A substantial fraction reported disturbed body perception and satisfaction with their own body image. These patients have not yet found their place between somatic medicine and psychotherapy: Although somatic und psychological symptoms coexist to a similar degree, patients tend to focus predominantly on their somatic complaints.

Medical education in Germany.

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.

Effects of medical training scenarios on heart rate variability and motivation in students and simulated patients.

CONTEXT: Research regarding the experience of stress during medical training scenarios using standardised patients (SPs) has been primarily qualitative and has focused on the SPs. The purpose of this study was to quantitatively evaluate stress and motivation in both students and SPs during these scenarios by measuring heart rate variability (HRV) and administering the German version of the Questionnaire on Current Motivation (QCM). METHODS: A total of 44 medical students (23 women, 21 men) participated in two medical history-taking training scenarios. In one scenario the SP role-played a patient with a somatic disease; in the other the SP played a patient with a psychosomatic disease, creating easy and difficult scenarios, respectively, for the student. Each student interviewed one of 11 SPs (five women, six men), using the same SP in both scenarios. Heart rate variability was measured during baseline periods and during the training scenarios in both students and SPs. Motivation was assessed before each training scenario. RESULTS: Heart rate variability was lower in both students and SPs during the scenarios compared with baseline values, but did not differ by scenario type. For students, motivation increased when the first scenario involved psychosomatic illness, but decreased when the first condition was somatic. For SPs motivation was consistent over time for scenarios involving psychosomatic disease, but decreased for somatic disease-related scenarios. CONCLUSIONS: The training scenarios induced stress in both students and SPs, as indicated by decreased HRV. Student motivation was high, indicating that SP scenarios represent a valid teaching method. Further studies in the natural setting of SP examinations are needed.

[Workplace learning for final-year medical students: a comprehensive analysis of student's expectancies and experiences]. / Lernen am späteren Arbeitsplatz: Eine Analyse studentischer Erwartungen und Erfahrungen im "Praktischen Jahr".

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Gender and the nocebo response following conditioning and expectancy.

OBJECTIVE: To investigate the role of Pavlovian conditioning and expectancy and of gender on the nocebo effects. METHODS: Conditioning experiment: Forty-eight healthy male and female volunteers were investigated for 3 days using a standard rotation procedure. Subjects in the experimental group received a salient oral stimulus prior to rotation; subjects in the control group received the stimulus 12 h after rotations on Days 1 and 2; on Day 3, all subjects received the stimulus prior to rotation. Expectancy experiment: Another 48 healthy subjects were rotated 5 x 1 min once only. All subjects received the same oral stimulus immediately prior to rotation; subjects in the experimental group were told that the symptoms might worsen with the stimulus; controls did not receive additional information. In both experiments, symptom rating (SR) and rotation tolerance (RT) were determined. RESULTS: Conditioning significantly reduced RT (P=.015) and increased SR (P=.024). For both RT and SR, a significant "day x group x gender" effect was found (P=.044; SR: P=.011) indicating that conditioning was more effective in women. Expectancies lowered RT (P=.085) without affecting SR. There was a significant "rotation x gender" interaction on RT (P=.005) indicating that the expectancy was more effective in men. CONCLUSION: Women responded stronger to conditioning while men responded to expectancies, but to a lesser degree. It needs to be determined whether this is restricted to nausea-specific conditions or can be generalized across clinical and experimental conditions.

[Self-image, real physician's and ideal physician's image: a comparison of medical students 1981 and 2006]. / Selbstbild, Arztbild und Arztideal: Ein Vergleich Medizinstudierender 1981 und 2006.

BACKGROUND: Due to the new licensing regulations for physicians, social and communicative aspects have attained a central position within medical education. In developing self-reflexive, empathetic and communicative skills, medical students are influenced on the one hand by encounters with real physicians in the role of supervisor or colleague, and on the other by their intra-psychic ideals and role stereotypes. The present study aimed to contrast the self-evaluations of modern medical students with their role stereotypes and ideals, and to further relate these to the evaluations, stereotypes and ideals of medical students in 1981. METHODS: 696 medical students were surveyed with respect to their self-image, their image of a physician and their image of the ideal physician using Osgood and Hofstätter's polarity profile. RESULTS: Over the past 25 years, medical students' image of the ideal physician has remained surprisingly constant, comprising expectations with regard to aptitude, trustworthiness, reliability, friendliness, confidence, thoroughness and congeniality. Encountered physicians were described as negatively deviating from this ideal; self-evaluations lay predominantly in between these two extremes. Self-images were characterized by feelings of powerlessness and uncertainty. CONCLUSIONS: Medical students possess differentiated images of self, future colleagues and the ideal physician. Surveyed students appeared to develop feelings of powerlessness and uncertainty, as well as tendencies to overestimate themselves within self-evaluations. Dealing with the conflict-charged domain between idealism and realism within the occupational reality toward which medical students aspire thus appears to be complicated. These problem areas, which have so far received little attention, require urgent consideration in the development of future medical curricula, in particular in the psychosocial fields.

Psychological effects of prevention: do participants of a type 2 diabetes prevention program experience increased mental distress?

OBJECTIVE: To evaluate the mental health outcome of a lifestyle intervention for the prevention of type 2 diabetes and to exclude possible harmful psychological effects. BACKGROUND: There is little empirical data on potential harmful effects of prevention programs. However, information, education, diagnostic procedures, phenotyping and risk assessment may cause or intensify psychological distress such as anxiety, depression or somatization in vulnerable individuals. METHODS: The Tuebingen Lifestyle Intervention Program (TULIP) for the prevention of type 2 diabetes has assessed mental health outcome in the participants after 9 months of program participation using the Symptom Checklist-90-R (SCL-90-R). The 24-months lifestyle intervention TULIP comprises regular exercise and changes in nutrition and assesses both, a broad range of somatic parameters as well as psychometric variables. For an interim analysis of psychological outcome, complete data sets of the SCL-90-R assessed at baseline and after 9 months of intervention were available for 195 participants (125 females, 70 males; age: 46.1 +/- 10.6 years). Data on somatization, anxiety, depression and overall psychological distress were compared to baseline levels. RESULTS: SCL-90-R scores of the TULIP-participants did not significantly differ from the German healthy reference population. Compared to baseline, a significant decrease in SCL-90-R scores was found for anxiety, depression and overall psychological distress at re-assessment after 9 months. CONCLUSION: The interim analysis on mental health outcome of a type 2 diabetes prevention program comprising extensive phenotyping and risk assessment rules out adverse psychological effects, suggesting rather beneficial changes concerning symptoms of anxiety, depression and overall psychological distress.

Peer-assisted versus faculty staff-led skills laboratory training: a randomised controlled trial.

OBJECTIVES: Although peer-assisted learning (PAL) is widely employed throughout medical education, its effectiveness for training in technical procedures in skills laboratories has been subject to little systematic investigation. We conducted a prospective, randomised trial to evaluate the hypotheses that PAL is effective in technical skills training in a skills laboratory setting, and PAL is as effective as faculty staff-led training. METHODS: Volunteer Year 3 medical students were randomly assigned to one of three groups. Two of these received regular skills training from either cross-year peer tutors or experienced faculty staff. Following training, both groups were assessed using an objective structured clinical examination (OSCE) (three stations assessing various injection techniques) which was video-recorded. Two independent video assessors scored the OSCEs using binary checklists and global ranking forms. A third student group was assessed prior to training and served as a control group. RESULTS: A total of 89 students (mean age 23.0 +/- 0.2 years; 41 male, 48 female) agreed to participate in the trial. Confounding variables including prior training as a paramedic or previous experience in performing the technical procedures did not significantly differ between the three study groups. In the OSCE, PAL (58.1 +/- 1 binary points, 4.9 +/- 0.1 global ranking points) and faculty-led groups (58.3 +/- 1 binary points, 4.7 +/- 0.1 global ranking points) scored significantly higher than the control group (33.3 +/- 1 binary points, 2.7 +/- 0.1 global ranking points; all P < 0.0001). There was no significant difference between the PAL and faculty-led groups (P = 0.92 for binary checklists, P = 0.11 for global rankings). CONCLUSIONS: Peer-assisted learning is a successful method for learning technical procedures in a skills laboratory setting and can be just as effective as the training provided by experienced faculty staff.

Vomiting and feeling fat--coincidence of achalasia and bulimia nervosa.

OBJECTIVE: In clinical practice it is often difficult to distinguish between organic and psychological vomiting. METHOD: We present a case of a 34-year-old woman with an 18-month history of vomiting with the initial diagnosis of bulimia nervosa (BN). However, the patient showed an unusual vomiting behavior. Therefore, further somatic diagnostic procedures were carried out leading to the additional diagnosis of achalasia. After successful interventional and surgical treatment for achalasia, further psychotherapeutic interventions were necessary because of worsening of the BN symptoms. A certain disturbed eating behavior seemed to persist at 3-year follow-up, while the medical condition had improved. CONCLUSION: It needs to be emphasized that careful diagnostic steps are indispensable to distinguish between psychological vomiting and organic vomiting. In case of two separate diseases a suitable treatment regime for each is required.

Undergraduate technical skills training guided by student tutors--analysis of tutors' attitudes, tutees' acceptance and learning progress in an innovative teaching model.

BACKGROUND: Skills labs provide a sheltered learning environment. As close supervision and individual feedback were proven to be important in ensuring effective skills training, we implemented a cross-year peer tutor system in our skills lab of internal medicine that allowed intense training sessions with small learning groups (3-4 students) taught by one student tutor. METHODS: The expectations, experiences and criticisms of peer tutors regarding the tutor system for undergraduate skills lab training were investigated in the context of a focus group. In addition, tutees' acceptance of this learning model and of their student tutors was evaluated by means of a pre/post web-based survey. RESULTS: 14 voluntary senior students were intensely prepared by consultants for their peer tutor activity. 127 students participated in the project, 66.9% of which responded to the web-based survey (23 topics with help of 6-point Likert scale + free comments). Acceptance was very high (5.69 +/- 0.07, mean +/- SEM), and self-confidence ratings increased significantly after the intervention for each of the trained skills (average 1.96 +/- 0.08, all p < 0.002). Tutors received high global ratings (5.50 +/- 0.07) and very positive anonymous individual feedback from participants. 82% of tutees considered the peer teaching model to be sufficient, and a mere 1% expressed the wish for skills training to be provided by faculty staff only. Focus group analyses with tutors revealed 18 different topics, including profit in personal knowledge and personal satisfaction through teaching activities. The ratio of 1:4 tutor/tutees was regarded to be very beneficial for effective feedback, and the personalized online evaluation by tutees to be a strong motivator and helpful for further improvements. The tutors ascribed great importance to the continuous availability of a contact doctor in case of uncertainties. CONCLUSION: This study demonstrates that peer teaching in undergraduate technical clinical skills training is feasible and widely accepted among tutees, provided that the tutors receive sufficient training and supervision.

[Final-year medical students as tutors for undergraduate students during their on-ward courses in internal medicine: a quantitative analysis]. / PJ-Studenten als TutorInnen für Medizinstudie- rende beim Stationseinsatz in der Inneren Medizin: Eine quantitative Analyse.

INTRODUCTION: Peer-assisted learning is a common feature of medical education and proves to be highly effective in many areas. So far there have been no reports on on-ward tutorials held by final-year students to promote the clinical competencies of medical undergraduates. The aim of the current investigation was to both evaluate undergraduate and tutor acceptance of a peer-assisted learning programme performed by final-year students and to examine the perception of the role of final-year students within an intervention and a control group. METHOD: 88 medical students (51 female, 37 male; mean age 23.6 years) were assigned to one of seven intervention wards where 10 student-led, patient-centred tutorials were held. 80 medical students (58 female, 22 male; mean age 23.3 years) were assigned to one of seven control wards. Tutorials were held by 14 volunteer final-year student tutors (8 female, 6 male; mean age 26.2 years). Acceptance of the peer-assisted learning programme and ratings of the role of final-year students were evaluated on a six-point Likert scale (ranging from 1 = very good to 6 = unsatisfactory and 1 = completely agree to 6 = completely disagree). RESULTS: Medical undergraduates rated student-led tutorials and tutors rated the introductory course and the complete programme as extremely positive (1.14 +/- 0.36 to 2.34 +/- 1.15). The role of final-year students as role model, teacher, contact person and integrator was rated as being significantly more relevant by students in the intervention group than by those in the control group (p < 0.02 in each case). DISCUSSION: Patient-centred, student-led on-ward tutorials designed to promote undergraduate clinical competencies received extremely positive ratings from both medical undergraduates and tutors and enable final-year tutors to assume important roles.

[What follows the diagnosis of a somatoform disorder?--An empirical study on health condition and health care utilisation two to four years after psychosomatic consultation in a university hospital]. / Was folgt der Diagnose einer somatoformen Störung?--Eine empirische Untersuchung zu Befindlichkeit und Inanspruchnahme medizinischer Versorgung nach psychosomatischer Konsiliaruntersuchung in einer Universitätsklinik.

Many hospitals provide psychosomatic consultation services for patients with unclear physical symptoms. The present follow-up-study aimed to analyse the situation of patients with somatoform disorders (ICD-10 F45) after psychosomatic consultation. It was performed at two times, in 1995 and 2004. Two to four years after psychosomatic consultation, 37 respectively 79 former patients answered a questionnaire on symptom load, psychosocial impairment and health care utilisation as well as the Screening of Somatoform Disorders SOMS-2. The results of both samples show the majority of patients to have persistent symptoms with considerable psychosocial impairments. The utilisation of outpatient psychotherapeutic treatment is insufficient. New concepts of psychosomatic consultation services have to be realized in cooperation with general practitioners. They should focus on motivating patients for psychotherapy.

[Working on the ward as part of the medical school curriculum: the influence of final year students on learning outcomes of medical students in their 7th semester and their feeling integrated]. / Einsatz auf Station innerhalb der Medizinischen Ausbildung: Einfluss von PJ-Studenten auf den Lernerfolg und das Integrationsgefühl von Medizinstudenten des 7. Semesters.

INTRODUCTION: 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. METHODS: 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. RESULTS: Medical students working on the wards of academic hospitals were significantly more frequently co-supervised by senior physicians (p < 0.001), while a higher level of co-supervision by final year students was reported for the University Clinic (p < 0.001). Students supervised by final year students reported greater subjective learning outcomes (p < 0.001). However, this had no effect on the extent to which students felt integrated on the ward. DISCUSSION: 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.

[Medical education in the field of psychosomatic medicine and psychotherapy at the German universities in 2006]. / Der Unterricht im Fach "Psychosomatische Medizin und Psychotherapie" an den Hochschulen der Bundesrepublik Deutschland nach Anderung der Approbationsordnung für Arzte.

BACKGROUND: The new licensing regulations for physicians introduced in 2002 place core competencies in the field of Psychosomatic Medicine and Psychotherapy at the centre of medical training and have been considered to constitute a favourable opportunity for psychosocial faculties. To date, no data have been published concerning the consequences of these new regulations. METHODS: All 34 chairs of Psychosomatic Medicine and Psychotherapy currently held by professors were surveyed by means of a written questionnaire at the beginning of the year 2006, regarding the present teaching situation and changes occurring through the introduction of the new regulations, as well as particular problem areas and respective solutions and suggestions. RESULTS: The rate of return for the questionnaires was 100 %. The consequences of the new regulations were rated predominantly positively. From a content point of view, classes continue to be more heavily weighted in cognitive areas and less so in areas of clinical practice; demands for an emphasis on affective learning objectives hence appear to have not been adequately met thus far. The newly established course formats (cross-sectional areas, obligatory optional courses, tutorials) also appear to have been employed to a rather limited degree. In addition to a lack of resources, the co-ordination with other specialist areas as well as the adequate assessment of teaching content poses a particular problem. DISCUSSION: The field of Psychosomatic Medicine and Psychotherapy constitutes an important engine for the didactic and content-related advancement of the medical curriculum in Germany. Nevertheless, the opportunities which the new licensing regulations for physicians offer to psychosocial faculties have not yet been entirely made use of. Surveyed individuals consider nationwide agreement concerning learning objectives, an exchange of experiences regarding the efficient and creative use of available resources and the development of suitable assessment methodologies, to be tasks to be urgently undertaken.