[Equivalency examinations for foreign physicians in Baden-Wuerttemberg]. / Gleichwertigkeitsprüfung für ausländische Ärzte/Ärztinnen in Baden-Württemberg.

INTRODUCTION: Recent years have seen an increasing number of foreign doctors starting to practice medicine in German hospitals (or more rarely, in surgeries). In order to be granted the German license to practice medicine, doctors with a medical degree from outside the European Union have to undergo an equivalency examination. The supervisory authority for this is the examination office of the relevant federal state, which is why different procedures are being applied in the individual states. The aim of this paper is to point out the problems that frequently arise when conducting this specialist exam and to make suggestions as to how to improve the quality of the procedure. METHOD: 6 senior professors from the examination boards of the 4 medical schools in Baden-Wuerttemberg formed a focus group and discussed the difficulties associated with the exam, recorded problems in its actual implementation and then analysed the minutes of the meeting in a results-based manner in order to compile proposals for optimisation. RESULTS: In view of the deficits in subject knowledge, general communication skills and specific communication skills, the difficulties of the current recognition procedure and the existing equivalency exam fall into 3 categories: structure and content of the exam, examiners and exam candidates. CONCLUSIONS: In consultation with the State Examination Office Stuttgart, some processes for optimisation have been devised, e. g., to develop a special curriculum which could be used for guidance and to recruit more examiners. The recommendations of the focus group from Baden-Wuerttemberg are an important step towards more transparency and possibly towards a Germany-wide standardisation of this exam.

[Quality of primary medical care after in-patient stroke rehabilitation]. / Versorgungsqualität von Patienten nach Schlaganfallrehabilitation. (Hausärztliche Nordbaden-Schlaganfallnachsorgestudie [HANS]).

PURPOSE: Since only insufficient information concerning the further development of patients after stroke and rehabilitation is currently available, and since the quality of care provided by family doctors is often classified as insufficient, this quality of care was to be examined on the basis of the rehabilitation results. Of particular interest were the co-operation, the therapeutical quality standards and the risk management, as well as the quality of life and compliance of the patients. METHODS: In 2000, all 223 stroke patients were asked prior to their discharge from three large rehabilitation clinics in North Baden, and subsequently their 210 family doctors, whether they were prepared to participate in this follow-up study. The participating patients were examined at their discharge from the clinic as well as 6 and 18 months later using a standardised documentation package, and quality circles for family doctors were initiated. RESULTS: All patients with atrial fibrillation were treated to prevent thrombosis. Smoking showed a positive trend. Quality of life and knowledge of the sickness trend to increase, depressiveness decreases. 60 % of the contacted family doctors participated in the study, 29 % (33 out of 114 physicians at the end of the study) contributed to improve interdisciplinary co-operation. Although 87 % of the patients said to be well informed, 25 % were dissatisfied with their own compliance. CONCLUSION: The quality of care of stroke patients by family doctors as assessed by indicators for secondary prevention and quality of life is satisfactory under present conditions. Apart from the hypertension control there was no negative trend. However, participation of GPs was insufficient. Co-operative after-care by GP can relatively easily stabilise health conditions following inpatient rehabilitation.

[What students and teaching doctors in Heidelberg think about early patient contact and tasks in general practice]. / Was denken Heidelberger Studierende und Lehrärzte über frühzeitige Patientenkontakte und Aufgaben in der Hausarztpraxis?

BACKGROUND: In Heidelberg, the clinical curriculum of medical education was fundamentally changed in 2001 due to co-operation with the Harvard Medical School. The pre-clinical curriculum has also already been undergoing reform since 1995: the benefits of two new lectures with early patient contact and special tasks in the subject of family medicine were to be assessed. METHODS: In the first year, the students therefore had to assess the seminars, tutorials, and the internships in GP by means of a standardised questionnaire. In addition, reports had to be produced on teaching practice. The teachers were also questioned following agreement with and introduction of quality assurance measures. RESULTS: 66-89% of students assigned good marks to the internships in GP, 40-58% for the accompanying seminars, and 70% for the tutors. The results of a general external evaluation which was carried out slightly differently were not quite so good. 87-89% of teachers agreed upon the elaborated criteria for the quality of teaching practice. CONCLUSIONS: The results show that GP-based education is already well accepted in the first year of training, and that early patient contact in primary care is highly appreciated by the students. On their part, the teaching GPs assess the quality promotion sessions as instruments towards continuous quality support in pre-clinical training as meaningful and necessary, especially with regard to licensing for teaching in General practice.

Effectiveness of a decentralized, community-related approach to reduce cardiovascular disease risk factor levels in Germany.

AIMS: Conventional community-oriented prevention programmes have been moderately successful in reducing cardiovascular disease risk factor levels in the population. Within the German Cardiovascular Prevention Study, a new decentralized and community-related form of preventive intervention was tested. METHODS AND RESULTS: Interested lay people and general practitioners co-operated in developing activities conducive towards a healthier lifestyle in two towns. Changes in risk factor levels were evaluated by repeated surveys of independent cross-sectional samples in two intervention communities (n=3460, baseline; 2561, final). National survey data (n=4788, baseline; 5311, final) were used to describe secular trends. Six years after the onset of intervention activities the following changes in risk factor prevalence for both sexes combined were observed in the intervention communities (95% CI in brackets): smoking -10.5% (-17.6 to -3.4); hypertension -29.0% (-38.1 to -19. 9); total cholesterol >/=250 mg. dl(-1)-8.1% (-15.4 to -0.9). In contrast to a national increase in the prevalence of obesity, this rate remained stable in the intervention communities. CONCLUSION: Initiating preventive activities developed by community members under the responsibility of local doctors is effective in lowering cardiovascular risk factors at community level. Unlike traditional intervention programmes this new approach does not require external funding and guidance.

[Quality assurance (general) at the medical school of Heidelberg as a model]. / Qualitätsförderung (allgemein-) medizinischen Hochschulunterrichts im Rahmen des Heidelberger Modells.

Because of new social and professional challenges, especially in the developed countries, there is a trend towards change and quality assurance is taking place in medical education over the past 20 years. In Heidelberg, the new way of teaching the students by general practitioners includes quality assurance by questionnaires, reports of practice visits, quality conferences of the teachers, and co-operation of the students. 90% of the students recommended the practice-based structured program as very useful, especially the work with the patients in the general practices, 87% of the teaching general practitioners accepted special criteria for teaching; by this way an academic general practice can be established to meet the future expectations of primary medical care.

Correlation of hemodynamic and functional variables with the angiographic extent of peripheral arterial occlusive disease.

The aim of the study was to determine whether hemodynamic and functional variables are related to the angiographic extent of lower limb atherosclerosis. In 150 patients with stable intermittent claudication, the Bollinger angiogram score was compared with the resting Doppler pressure values, and the initial claudication distance (ICD) and absolute claudication distance (ACD) with treadmill exercise. The extent of lower limb atherosclerosis correlated significantly with the age of the patients and the duration of the claudication. The angiogram scores of the patients were negatively correlated with the ankle systolic blood pressure (SBP) and the ankle/brachial index (ABI). In a multiple regression analysis, ABI was the most predictive variable for the angiographic severity of disease. ICD, ACD and work on the treadmill failed to correlate with the angiogram summation score. If patients were classified into groups for those with iliac or femoropopliteal disease, a weak correlation between ACD and femoropopliteal angiogram score was found. The comparison between Doppler measurements and treadmill exercise testing showed no significant correlation between SBP/ABI of the more diseased limb and ICD. However, both SBP and ABI did correlate significantly with ACD (r = 0.16, p < 0.05 and r = 0.20, p < 0.01, respectively). In conclusion, SBP and ABI are reliable parameters for indirect assessment of the angiographic extent of lower limb atherosclerosis. In contrast, the walking capacity of claudicant patients is independent of the angiographic severity of the disease.

[The problem of evidence-based guidelines using the example of the treatment of obesity]. / Zur Problematik Evidenz-basierter Leitlinien am Beispiel der Adipositas-Behandlung.

Despite many therapeutic strategies used by experts and general practitioners, the obesity problem has still increased in the developed countries. Therefore it is necessary to provide evidence-based references for good clinical practice. The guideline presented in Cologne in 1997 was published in an improved form in 1998. However, the consequences and circumstances do not only promise benefit but lead to new questions: Where are the indications for implementation and the participation of the main users, the general practitioners? Why should the procedures of tests and consensus not used additionally? The co-morbidity, biography, genetics, and the number of relapses of patients are probably not emphasized enough, the use of drugs could be considered more carefully. Although the reviewed guideline is important, there is a lack in providing the information and in advice for procedures of co-operation in primary health care. The great therapeutic problem and understanding for the daily practice has not been estimated enough.

Relevance of claudication pain distance in patients with peripheral arterial occlusive disease.

BACKGROUND: Determination of both the pain-free and the maximum walking distances is part of a routine program in the angiological examination of patients with PAOD. It is however as yet not clear which of these two parameters is more relevant in determining a patient's pathological condition. PATIENTS AND METHODS: In 150 patients with stable intermittent claudication, the claudication pain distance (CPD) and the maximum pain distance (MPD) were determined on a treadmill at 3.0 km/h and 12% inclination. The results were compared with the angiographic findings, the Doppler pressure values and the subjective quality of life (PAVK-86-Questionnaire). RESULTS: The average pain-free walking distance was 89 +/- 71 m, and the maximum walking distance was 198 +/- 141 m. There was no correlation between both walking distances and the angiographic extent of PAOD. Only the MPD correlated with the ankle systolic Doppler pressure and the ankle/brachial pressure index of the claudicating leg (r = 0.16, p < 0.05 and r = 0.20, p < 0.01). Both the CPD and the MDP had a significant influence on the life quality of the patients (CPD: r = -0.41, p < 0.001; MPD: r = -0.47, p < 0.001). In the multiple regression analysis, beside the body mass index, the MPD was found to be the greatest predictor for the pathologically relevant quality of life dimensions pain, complaints and functional status. CONCLUSIONS: The maximum walking distance correlated in a better way than pain-free walking distance with the objective and subjective assessment criteria of PAOD. Therefore, as regards the stage of the disease and the life quality of the patient, this parameter has a greater importance. This fact deserves to receive greater attention in everyday clinical practice and when conducting clinical trials.

Contribution of angiotensin I converting enzyme gene polymorphism and angiotensinogen gene polymorphism to blood pressure regulation in essential hypertension.

The renin-angiotensin system (RAS) is involved in the pathogenesis of essential hypertension. In the present study we examined the genotype frequencies of the insertion/deletion polymorphisms of the ACE gene and the M235T polymorphism of the Angiotensinogen (Agt) gene in patients with essential hypertension in comparison with normotensive subjects. In hypertensive patients functional effects of blood pressure response to ACE inhibition were investigated. A total of 121 patients with essential hypertension (group 1) and 125 normotensive control subjects (group 2) were included in this study. All patients were genotyped by polymerase chain reactions (PCR) for the insertion/deletion (I/D) polymorphism of the ACE gene and the M235T polymorphism of the Agt gene. To analyze possible functional impacts on blood pressure regulation 50 mg of captopril was administered to hypertensive patients. No significant association of essential hypertension with polymorphisms of the Agt and ACE gene was found. The ACE serum levels in patients with the DD-genotype of the ACE I/D polymorphism were higher than in patients with the II-genotype (P < .01). In patients with the ID-genotype the ACE serum levels were in-between. A captopril test was performed in hypertensive patients. The patients were further divided into subgroups according to the diastolic and systolic blood pressure response. Group 1a consisted of patients with a diastolic blood pressure drop of > 5 mm Hg and group 1b with < or =5 mm Hg. Group 1c consisted of patients with a systolic blood pressure drop of > 10 mm Hg and group 1d with < or =10 mm Hg. Twice as many patients with the DD genotype of the ACE gene were found in group 1a compared to group 1b (chi(2) = 5.673; P = .017). No association of systolic blood pressure change to the investigated polymorphisms was found. Our results do not support the hypothesis that the investigated polymorphisms contribute to essential hypertension. Furthermore, no major impact of these polymorphisms on blood pressure response to captopril were detected. We conclude that the investigated genotypes have no influence on blood pressure level and homeostasis.

Nutritional counseling in German general practices: a holistic approach.

There is consensus among all German health professionals, including primary care physicians, that a holistic approach to healthy living begins with good nutrition. In northern Baden, 2100 general practitioners and internists were asked about their nutritional attitudes and preventive counseling in daily practice. Of responding physicians, 75% attributed great importance to prevention in general and 92% to nutrition in particular, 65% were providing special programs such as "How to treat diabetes by myself" or "Reducing hypertension by losing weight." Together with the highest German Committee of Physicians, the Lectures in General Medicine of the University of Heidelberg held a meeting on nutritional counseling in general practice. The 23 participants collected statements and information on the topics of education and counseling, support for improved teaching, and knowledge about nutritional attitudes and food. The Heidelberg agreements are as follows: 1) good nutritional counseling can reduce morbidity of important diseases, 2) nutritional counseling must be improved in general practice, 3) diagnosis-related written cases for systematic counseling should be available, 4) family doctors should cooperate with nutritionists, and 5) for quality assurance, the three-level strategy of primary care should be recommended because of the positive results of the Bruchsal-Oestringen program (reduction of obesity and hypercholesterolemia). General practice can become a place of improved nutritional counseling and education if the use of programs proven to be successful, additional exercise-based community approaches, and quality assurance can be facilitated. The outcome of practice-based studies may encourage primary care physicians to spend more time and training on nutrition guidance.

Four years of practice-based and exercise-supported behavioural medicine in one community of the German CINDI area. Countrywide Integrated Non-Communicable Diseases Intervention.

The main goal of the preventive intervention study in one community of the German CINDI (Countrywide Integrated Non-Communicable Diseases Intervention programme of the WHO) area was to improve cardiovascular health by reducing the risk factors smoking, hypertension, obesity, hypercholesterolaemia, and by changing sedentary lifestyle. The intervention was performed by using the special "Three-Level-Strategy", which is characterised by activities of primary care physicians in the usual consulting hour (1st level), with patient groups in their practices (2nd level), and at community level (3rd level) where a special work group and a co-ordinating general practice are co-operating. To evaluate the occurrence of the risk factors in practice and the local population, four cross-sectional random samples (N(total) = 4881) were carried out in seven practices from 1992 to 1995. On the community level, 23 special exercise-based health groups (N(total) = 600) were established and were investigated by means of a questionnaire, related to behaviour and health beliefs. A "Local Health Information System" facilitated the evaluation, the management of the data, and the organisation of the health programme. The results of the practice samples showed a significant reduction of smoking (-17.8%) and hypertension (-31.5%) (p < 0.01). The exercise-based groups were combined with nutritional counselling or relaxation and were accepted very well by the participants (83.8%). The participants considerably improved their health behaviour: 82% discussed health in their family, 37.3% stated an increase of healthy nutrition, 52% of relaxation; 86.2% intended to regularly increase physical activity in leisure time and 82 % could not imagine regular health training without exercise meetings. We conclude that the practice-based "Three-Level-Strategy" provides a strong support for successful long-term prevention of cardiovascular risk, particularly, when exercise-based health training sessions are performed in order to change sedentary lifestyle. When organised on community level, they might have a positive impact on the health behaviour of the whole community. Physical activity can be used as a "prodrug" for health promotion in a holistic way.

[CINDI (Countrywide Integrated Noncommunicable Diseases Intervention) in Germany. A model for life style oriented, medical primary care for the population]. / CINDI Germany. Ein Modell zur lebensstilorientierten, ärztlichen Primärversorgung der Bevölkerung.

The WHO project "CINDI" (Country-wide Integrated Noncommunicable Diseases Intervention) is being implemented in 23 European countries and in Canada. The central goal of this project is the development of across-country strategies to combat chronic diseases caused by unhealthy lifestyles. The more Europe grows together the more it will be necessary to have such strategies. The health sector of the individual countries is shaped by cultural and/or civilizatory conditions. Such a strategy has to account for the country's specific shape of the health sector and the experience made in this point has to result in the establishment of structures and the creation of measures across Europe and worldwide. In the first step, members of the CINDI family are to ascertain country specific informations which in the second step should be used for the development of the strategy. The paper refers to the contribution made so far by CINDI Germany with regard to the first step. The "3 Level Conception of Family Physicians"-recommended by the Society of physicians of Germany the model "Community - related behavioural medicine" - which has been developed to put the above mentioned conception into practice - and quality assurance in the framework of medical primary care from the focus of the paper.

[The Ostringer (Prevention) Model. Results of family medicine supervised "community behavioral medicine"]. / Das Ostringer (Präventions-) Modell. Ergebnisse hausärztlich verantworteter "gemeindebezogener Verhaltensmedizin".

To evaluate the German intervention model of "Community-related Behavioural Medicine" in reducing cardiovascular risk during a major prevention study (phase I) and to investigate the efficiency of a long-term evaluation by establishing a Local Health Information System for which cooperating primary care physicians carry responsibility (phase II). In the intervention city of Bruchsal (GCP evaluation, phase I), the cardiovascular risk factors were reduced: smoking (-9.4%), obesity (-17.1%), hypertension (-51.4%) and hypercholesteremia (-12.8%). In the general practices of Oestringen (LOHIS-evaluation, phase II), the prevalence of smoking, from 1992 to 1994 (-23.8%, p < 0.01) as well as hypertension (-22.2%), p < 0.01) continued to decrease; there was no further reduction of hypercholesteremia and over-weight.

[What can family physicians contribute to health promotion in schools?]. / Welchen Beitrag können niedergelassene Arzte zur Gesundheitsförderung an Schulen leisten?

Although several German schools have developed and tested concepts of a goal-directed health education, a stable and continuous implementation is missing. In this field free-practising physicians can support public health efforts. In the area Bruchsal/Ostringen it is demonstrated, that especially those primary care physicians, who work according to the "Three-Level-Concept of Free-Practising Physicians", can successfully use their geographical and social proximity to schools in their neighbourhood for a log-lasting implementation of recurring health-related activities. Within ten years 1389 students in schools, further ca. 500 outside schools, were directly included in interactive learning in the framework of preventive measures, e.g. during school health days. 10 physicians (4 of them continuously) cooperated in these activities, which had been planned in close collaboration with teachers and parents, considering the different age groups. From the very beginning--although sometimes limited in scale--each activity was evaluated. Pupils in the age group 10-12 years generally showed the highest interest in health-related diet, 17-26% were physically more active. Promising are the results with respect to smoking: one fifth of the smoking students intended to quit as a consequence of the health activities in their schools.