Working as simulated patient has effects on real patient life - Preliminary insights from a qualitative study.

BACKGROUND: Persons who simulate patients during medical education understand the routines and the underlying script of medical consultations better. We aimed to explore how simulated patients (SPs) integrated this new understanding into their daily life, how this work affected their private life as patients, and what we can learn from these changes for concepts of empowerment. DESIGN, SETTING, AND PARTICIPANTS: A qualitative interview study. All SPs of Göttingen medical school who had been working longer than three semesters (n=14) were invited and agreed to take part in an open interview about their daily experience with real doctors. Documentary method was used to identify the main issues. Several cases were chosen according to maximum contrast and analysed by in-depth analysis to provide vivid examples of how simulations may affect the real life of the SPs as patients. RESULTS: Our analysis revealed three main changes in the behaviour of SPs as real patients. They were more attentive, had a better understanding of the circumstances under which doctors work, and acted more self-confidently. From the selected cases it became apparent that working as a SP may lead to a constant and significant decrease of fear of hospitals and medical procedures or, in other cases, may enable the SPs to develop new abilities for giving feedback, questioning procedures, and explanations for real doctors. CONCLUSION: working as a simulated patient seems to be well-suited to understand own progression of diseases, to increase self-responsibility and to a confident attitude as patient.

Medical school admission test: advantages for students whose parents are medical doctors?

BACKGROUND: Admission candidates especially in medicine do not represent the socio-demographic proportions of the average population: children of parents with an academic background are highly overrepresented, and those with parents who are medical doctors represent quite a large and special group. At Göttingen University Medicine, a new admission procedure was established with the intention to broaden the base of applicants towards including candidates with previous medical training or lower final school grades. With a view to family background, we wished to know whether candidates differ in the test scores in our admission procedure. METHODS: In February 2014 we asked all admission candidates of Göttingen University Medicine by questionnaire (nine closed, four open questions) about the academic background in their families, specifically, the medical background, school exam grades, and previous medical training as well as about how they prepared for the admission test. We also analysed data from admission scores of this group (semi-structured interview and four multiple mini-interviews). In addition to descriptive statistics, we used a Pearson correlation, means comparisons (t-test, analysis of variance), ANOVA, and a Scheffé test. RESULTS: In February 2014 nearly half of the applicants (44%) at Göttingen University Medicine had a medical background, most frequently, their parents were physicians. This rate is much higher than reported in the literature. Other socio-demographic baseline data did not differ from the percentages given in the literature. Of all applicants, 20% had previous medical training. The group of applicants with parents who were medical doctors did not show any advantage in either test-scoring (MMI and interview), their individual preparation for the admission test, or in receiving or accepting a place at medical school. Candidates with parents who were medical doctors had scored slightly lower in school exam grades. CONCLUSION: Our results suggest that there is a self-selection bias as well as a pre-selection for this particular group of applicants. This effect has to be observed during future admission procedures.

[Medical school admission test at the University of Goettingen - which applicants will benefit?]. / Das neue Göttinger Auswahlverfahren für Medizin - welche Bewerber können profitieren?

Medical schools in Germany may select 60% of the student applicants through their own admission tests. The influence of the school-leaving examination grades (EGs) in each of the procedural steps is controversial. At Goettingen Medical School, we combine a structured interview and a communicative skills assessment. We analysed how many applicants succeeded in our admission test, compared to a model which only takes EGs into account. Admission scores were transferred into SPSS-21. Sociodemographic data were submitted by the Stiftung Hochschulstart. Besides descriptive statistics, we used Pearson-correlation and means comparisons (t-test, analysis of variance). 221 applicants (EGs 1.0-1.9) were invited in the winter semester 2013/14 and 222 applicants (EGs 1.1-1.8) in the summer semester 2014. The proportion of women was 68% (winter) and 74% (summer). Sixteen and 37 applicants had a medical vocational training and performed slightly better. The analysis showed that our test was gender neutral. EGs did not correlate with interviews or skills assessment. Despite a two-fold impact of EGs, 26 (winter) and 44 (summer) of the overall 181 applicants had EGs of 1.4 -1.9, which would have been too low for admission otherwise. If EGs were only considered once, 40 (winter) and 59 (summer) applicants would have succeeded.

Psychometric properties of the Calgary Cambridge guides to assess communication skills of undergraduate medical students.

OBJECTIVE: The aim of this study was to analyse the psychometric properties of the short version of the Calgary Cambridge Guides and to decide whether it can be recommended for use in the assessment of communications skills in young undergraduate medical students. METHODS: Using a translated version of the Guide, 30 members from the Department of General Practice rated 5 videotaped encounters between students and simulated patients twice. Item analysis should detect possible floor and/or ceiling effects. The construct validity was investigated using exploratory factor analysis. Intra-rater reliability was measured in an interval of 3 months, inter-rater reliability was assessed by the intraclass correlation coefficient. RESULTS: The score distribution of the items showed no ceiling or floor effects. Four of the five factors extracted from the factor analysis represented important constructs of doctor-patient communication The ratings for the first and second round of assessing the videos correlated at 0.75 (p<0.0001). Intraclass correlation coefficients for each item ranged were moderate and ranged from 0.05 to 0.57. CONCLUSIONS: Reasonable score distributions of most items without ceiling or floor effects as well as a good test-retest reliability and construct validity recommend the C-CG as an instrument for assessing communication skills in undergraduate medical students. Some deficiencies in inter-rater reliability are a clear indication that raters need a thorough instruction before using the C-CG.

Standardized and quality-assured video-recorded examination in undergraduate education: informed consent prior to surgery.

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

Do communication training programs improve students' communication skills?--a follow-up study.

BACKGROUND: Although it is taken for granted that history-taking and communication skills are learnable, this learning process should be confirmed by rigorous studies, such as randomized pre- and post-comparisons. The purpose of this paper is to analyse whether a communication course measurably improves the communicative competence of third-year medical students at a German medical school and whether technical or emotional aspects of communication changed differently. METHOD: A sample of 32 randomly selected students performed an interview with a simulated patient before the communication course (pre-intervention) and a second interview after the course (post-intervention), using the Calgary-Cambridge Observation Guide (CCOG) to assess history taking ability. RESULTS: On average, the students improved in all of the 28 items of the CCOG. The 6 more technically-orientated communication items improved on average from 3.4 for the first interview to 2.6 in the second interview (p < 0.0001), the 6 emotional items from 2.7 to 2.3 (p = 0.023). The overall score for women improved from 3.2 to 2.5 (p = 0.0019); male students improved from 3.0 to 2.7 (n.s.). The mean interview time significantly increased from the first to the second interview, but the increase in the interview duration and the change of the overall score for the students' communication skills were not correlated (Pearson's r = 0.03; n.s.). CONCLUSIONS: Our communication course measurably improved communication skills, especially for female students. These improvements did not depend predominantly on an extension of the interview time. Obviously, "technical" aspects of communication can be taught better than "emotional" communication skills.

Frequency and perceived severity of negative experiences during medical education in Germany--results of an online-survery of medical students.

AIMS: Negative experiences during the course of medical education have been reported in many countries, but little is known about the perceived severity of these experiences. We studied for the first time how often students at a medical university in Germany have had negative experiences, and how severe they perceive these to be. METHOD: We asked medical students in an online survey whether they felt adequately appreciated, had experienced peer rivalry, verbal abuse by their mentors, physical abuse or mistreatment, sexual harassment, racial or ethnic discrimination, or any other kind of mistreatment. RESULTS: Of 391 students, 56% stated that they felt insufficiently appreciated, 51% had experienced rivalry, and 34% had suffered verbal abuse. Fifty-nine percent of the students felt highly aggrieved because of verbal abuse, while 46% were aggrieved by the ongoing rivalry and 32% by the lack of appreciation. Significantly fewer students felt upset because they were passed over or ignored (21%). Generally, female students felt more often aggrieved by these negative experiences than their male colleagues. CONCLUSION: Of the possible negative experiences, the less prominent ones such as lack of appreciation or verbal abuse are not only frequent, they are also perceived as very upsetting. Medical teachers should reflect this more in their day-to-day dealings with students and aim to improve on their contact with the students accordingly.

Breaking bad news - an interdisciplinary curricular teaching-concept.

BACKGROUND: The concerns of patients suffering from life-threatening disease and end-of-life care aspects have gained increasing attention in public perception. The increasing focus on palliative medicine questions can be considered to be paradigmatic for this development. Palliative medicine became a compulsory subject of the undergraduate curriculum in Germany to be implemented until 2013. The preexisting conditions and qualifications at the medical faculties vary, though. We describe the conceptual process, didactic background, and first experiences with the new interdisciplinary course "Delivering bad news" as a compulsory part of the palliative medicine curriculum. METHODS: Since autumn 2009, this course has been taught at the University Medical Center Göttingen, consisting of two double lessons in the final year of medical education. Considering the curriculum-based learning goals in Göttingen, the focus of this course is to impart knowledge, attitudes and communication skills relating to "bad news". RESULTS: Although the seminar requires adequate staff and is time-consuming, students have accepted it and gave high marks in evaluations. In particular, the teachers' performance and commitment was evaluated positively. DISCUSSION AND CONCLUSIONS: We describe the first experiences with a new course. Didactic structure, theoretical contents, role-plays and usage of media (film, novel) are well- suited to communicate topics such as "bad news". Additional experiences and evaluations are necessary. According to the progressive nature of learning, it might be worthwhile to repeat communication- centered questions several times during medical studies.

Accepting the unacceptable: medication adherence and different types of action patterns among patients with high blood pressure.

OBJECTIVE: To gain deep insight into what it means for patients to live with drug-treated hypertension and to understand the implications for the doctors' influence on patients' adherence. METHODS: Group discussions with 43 drug-treated hypertensive patients. Documentary method was used for interpretative analysis. RESULTS: Four basic phenomena were identified (fear, ignorance, reluctance to discuss matters with the doctor, impact of illness experiences), which resulted in different types of action patterns: (1) the assertive actor, (2) the unconscious avoider, and (3) the inconsistent actor. The types of action patterns do not refer to any implications for adherence. The patients' action does not indicate their preferred model of doctor-patient interaction or their acceptance of taking medication. CONCLUSION: Adherence must not be seen as meaningless behaviour, which can simply be learned, but rather as the result of subjective experiences on living with hypertension and the ability to accept the diagnosis and its treatment. PRACTICE IMPLICATIONS: It is premature to initiate therapy straight after the diagnosis, before the patient is prepared to take the tablets. Supporting adherence means to stay in dialogue and to give the time, privacy and patience to enable patients to overcome their inhibitions of asking and to accept the therapy.

Implementing the cross-disciplinary subject of palliative medicine (Q13) against the backdrop of recent changes of the legal framework using University Medical School Göttingen as an example.

Palliative care for patients with advanced and progressive diseases has recently become an integrated and compulsory part of undergraduate training in Germany. Up until now, undergraduate teaching in this cross-disciplinary medical field varied and therefore problems during the implementation process with regard to formal aspects and teaching content are to be expected. This contribution summarizes the new legislative framework for palliative care as an independent specialty in undergraduate medical training and describes format, content and problems of the current implementation process at the University Medical School Göttingen, in order to provide advice and support for other faculties.

Psychosocial determinants for frequent primary health care utilisation in patients with heart failure.

OBJECTIVE: Psychosocial symptoms are common in patients with heart failure. Little research, however, has been done to determine which psychosocial factors influence primary care patients' consultation frequency in the case of heart failure. METHODS: We recruited 310 primary care patients with heart failure by analysing electronic patient records. At baseline, psychological distress (anxiety and depression; HADS), disease coping (FKV), negative affectivity and social inhibition (DS-14), disease-specific quality of life (MLHFQ) and social support (F-SozU) were measured by validated questionnaires. Severity of heart failure (according to NYHA-classification and Goldman's Specific Activity Scale) and sociodemographic characteristics were documented by self-report instruments. Nine month later, patients were contacted by telephone in order to assess GP consultation frequency. Logistic regression was done to determine whether these psychological, medical and sociodemographic factors were associated with primary care utilisation. RESULTS: On average, patients consulted their general practitioner (GP) 8.2 times during nine months. Female subjects and patients with higher levels of perceived heart failure severity, physical problems and anxiety or depression as well as those living alone visited their GP significantly more often. In multivariate analysis, frequent attendance in general practices was predicted by physical problems and living alone. These factors explained 11.6% of the variance of frequent attendance in general practices. CONCLUSION: Psychosocial factors of help-seeking behaviour in heart failure patients focus on mental and physical discomfort and a lonely home situation. These factors might need to be compensated by GP consultation. GPs should address the rearrangement of physical, mental, and social resources to strengthen self-reliance of patients with heart failure.

Can student tutors act as examiners in an objective structured clinical examination?

CONTEXT: The dissemination of objective structured clinical examinations (OSCEs) is hampered by requirements for high levels of staffing and a significantly higher workload compared with multiple-choice examinations. Senior medical students may be able to support faculty staff to assess their peers. The aim of this study is to assess the reliability of student tutors as OSCE examiners and their acceptance by their peers. METHODS: Using a checklist and a global rating, teaching doctors (TDs) and student tutors (STs) simultaneously assessed students in basic clinical skills at 4 OSCE stations. The inter-rater agreement between TDs and STs was calculated by kappa values and paired t-tests. Students then completed a questionnaire to assess their acceptance of student peer examiners. RESULTS: All 214 Year 3 students at the University of Göttingen Medical School were evaluated in spring 2005. Student tutors gave slightly better average grades than TDs (differences of 0.02-0.20 on a 5-point Likert scale). Inter-rater agreement at the stations ranged from 0.41 to 0.64 for checklist assessment and global ratings; overall inter-rater agreement on the final grade was 0.66. Most students felt that assessment by STs would result in the same grades as assessment by TDs (64%) and that it would be similarly objective (69%). Nearly all students (95%) felt confident that they could evaluate their peers themselves in an OSCE. CONCLUSIONS: On the basis of our results, STs can act as examiners in summative OSCEs to assess basic medical skills. The slightly better grades observed are of no practical concern. Students accepted assessment performed by STs.

Learning core clinical skills--a survey at 3 time points during medical education.

BACKGROUND: It is generally unknown which clinical skills students acquire during medical education and which factors influence their levels of competence. METHODS: We asked German medical students how competent they felt in performing individual clinical skills. RESULTS: Third year students evaluated their competence in clinical skills, on average, not better than 4.7 on a Likert scale ranging from 1 (= 'excellent') to 6 (= 'insufficient'). The average score for fifth year students was 4.1, for final-year students 3.3. Deficits in all groups of students were most prominent in communication skills and diagnostic skills. CONCLUSIONS: These results are a plea for a structured curriculum including training courses to practice clinical skills.

[Prescription of generic drugs in general practice. Results of a survey of general practitioners]. / Verordnung von Generika in der hausärztlichen Praxis: Ergebnisse einer Befragung von Hausärzten.

BACKGROUND AND PURPOSE: Switching brand-name drugs to generics is reasonable and desired for economic reasons. Few data exist about problems, if any, during the switching in general practice. In this survey, the view of general practitioners (GPs) should be ascertained. METHODS: GPs in five counties in the German federal states Thüringen and Baden-Württemberg, who took part in a study on generic drug prescribing, were asked to complete a questionnaire about experiences and attitudes toward generic drug prescription. RESULTS: A total of 195 (84%) of 233 GPs answered the questionnaire. Two thirds (127/195) stated, that brands and generics are pharmacologically equivalent. Many of these GPs estimated to prescribe generic drugs in > 50% of instances; fewer doctors did so, if they had doubts as to the equivalence of generics (65% vs. 46%; p < 0.05). Nearly 8% reported generics being less effective, and 10% observed new adverse effects after switching. Many GPs appointed the following barriers: cooperation with hospitals and colleagues (86%), GP's lack of time (68%), and communication problems with the patient (50%). GPs estimated that > 10% of patients strictly reject generic drugs. CONCLUSION: An optimized cooperation between GPs and hospital physicians could facilitate the consumption of generic potential in pharmacotherapy. Reasons for the obvious contrast between the proven pharmacological equivalence of brand-name and generic drugs and the problems encountered after switching reported by GPs should be further studied.