Influence of medical didactic training on the self-efficacy and motivation of clinical teachers.

Objectives: Due to increasing workload and rising expectations for both undergraduate and speciality training in medicine, teaching in a clinical environment can be challenging. The "Train the Trainer" course, developed by CAL (Chirurgische Arbeitsgemeinschaft Lehre, Deutsche Gesellschaft für Chirurgie (DGCH)), aims to assist clinical teachers in their task. This study investigates the effect the course has on participants' self-efficacy and teaching motivation. Methods: Prior to attending the course, participants anonymously completed a 50-question pre-course questionnaire using standardised questions to gather information on biographical data teaching experience, and validated tools measuring teaching motivation and self-efficacy (PRE). Directly after completing the course, participants evaluated it using a 25-question post-course questionnaire (POST1). At least 12 months after the course, participants received a follow-up questionnaire (POST2) by mail. This 44-question form aimed to gather biographical data, review the teaching methods participants had used since their training, and reassess their teaching motivation and self-efficacy. Results: Between June 2016 and October 2019, 20 TTT courses were held across six German medical faculties. Data were gathered from 241 participants. After the course, 182 POST2 questionnaires were mailed, 61 of which were returned (equals a 39 % return rate). The findings revealed significant increases in teacher self-efficacy (p=0.0025), identified regulation (p=0.0000), and career motivation (p=0.0044). In contrast, there was a significant decrease in introjected regulation (p=0.0048). When comparing the participants to a reference sample selected from literature, significant differences emerged in intrinsic motivation (p=0.0000) and amotivation (p=0.0025). Conclusions: Course participants already showed strong intrinsic motivation and self-efficacy before taking the course. After completing it, their confidence to meet specific teaching demands based on their abilities had increased. Notably, changes in motivational dimensions identified and introjected regulation point towards a shift in motivational sources, indicating a more self-regulated approach towards participants' teaching activities. Further research is needed to determine how much of this change was due to course participation.

Communication skills of medical students: Evaluation of a new communication curriculum at the University of Augsburg.

Objectives: Teaching communication skills plays a pivotal role in medical curricula. The aim of this article is to describe and evaluate a new communication curriculum developed at the Faculty of Medicine, University of Augsburg (KomCuA), which was conceptualized by an interdisciplinary team based on recommended quality standards (i.e., helical, integrated, longitudinal). Methods: A total of 150 medical students enrolled in the 1st, 3rd, and ≥5th semester participated in the study. They completed an online survey (numerical rating scales and validated questionnaires) evaluating their current communication skills, how these developed across the curriculum in terms of quality and self-confidence, and how helpful they considered practicing in small group tutorials with simulated patients. The students' attitudes towards communication and empathy in the context of medical care were additionally assessed. The students' responses were compared across semesters using one-way univariate analysis of variance (ANOVA). Results: Overall, students reported improved communications skills due to attending the KomCuA and further considered practicing with simulated patients as being very helpful (large effect sizes). Compared to 1st semester students, 3rd and ≥5th semester students reported better communication skills (medium to large effect sizes). Additionally, ≥5th semester students showed stronger agreement towards the relevance of empathy in the context of medical care (medium effect size) compared to both 1st and 3rd semester students. Conclusion: The KomCuA has shown to be an effective communication curriculum to support medical students in the development of their communication skills and positive attitudes towards empathy. Additional studies assessing students' communication skills and empathic attitudes longitudinally are warranted to confirm the present results and to gain further knowledge on how these essential skills and attitudes develop across medical curricula.

Implicit expression of uncertainty in medical students during different sequences of clinical reasoning in simulated patient handovers.

Background: Dealing with medical uncertainty is an essential competence of physicians. During handovers, communication of uncertainty is important for patient safety, but is often not explicitly expressed and can hamper medical decisions. This study examines medical students' implicit expression of uncertainty in different sequences of clinical reasoning during simulated patient handovers. Methods: In 2018, eighty-seven final-year medical students participated in handovers of three simulated patient cases, which were videotaped and transcribed verbatim. Sequences of clinical reasoning and language references to implicit uncertainty that attenuate and strengthen information based on a framework were identified, categorized, and analyzed with chi-square goodness-of-fit tests. Results: A total of 6358 sequences of clinical reasoning were associated with the four main categories "statement", "assessment", "consideration", and "implication", with statements occurring significantly (p<0.001) most frequently. Attenuated sequences of clinical reasoning occurred significantly (p<0.003) more frequently than strengthened sequences. Implications were significantly more often attenuated than strengthened (p<0.003). Statements regarding results occurred significantly more often plain or strengthened than statements regarding actions (p<0.0025). Conclusion: Implicit expressions of uncertainty in simulated medical students' handovers occur in different degrees during clinical reasoning. These findings could contribute to courses on clinical case presentations by including linguistic terms and implicit expressions of uncertainty and making them explicit.

The WFME global standards for quality improvement of postgraduate medical education: Which standards are also applicable in Germany? Recommendations for physicians with a license for postgraduate training and training agents.

Background: In Germany, the (model) regulation for postgraduate medical education 2018, the professional codes of conduct of the regional medical councils and the health professions chamber laws of the federal states are the formal basis of postgraduate medical education, but say little about its structure, processes and results. The World Federation for Medical Education (WFME) has developed global standards for improving the quality of postgraduate medical education and published them in a revised edition in 2015. A German version which takes the specifics of medical training in Germany into account has not been published to date. Objective: The Committee for Postgraduate Medical Education (PGME) of the Society for Medical Education (GMA) has set itself the goal of firstly translating the WFME standards into German and secondly making recommendations for physicians with a license for post-graduate training (PLT) and training agents (TA) in clinics and practices which have been adapted to the German context. Methods: The WFME standards were translated into German by a working group of the GMA Committee for PGME, the terminology adapted to PGME in Germany and checked by an interdisciplinary panel of experts made up of 9 members of the committee. In a second step, the WFME basic standards and quality standards for PGME relevant to PLTs and TAs in Germany were iteratively determined by this panel of experts using the Nominal Group Technique (NGT) and compiled in the form of recommendations. Results: The translation of the WFME guidelines was approved by the expert group without any changes to the content, taking into account the terminological system of PGME in Germany. In a second step, 90 standards were identified which were considered helpful for PGME in Germany, especially for PLTs and TAs (such as development of a professional identity, a more patient-centered approach or support of self-directed learning). Care was taken to only give recommendations which can be influenced by PLTs and TAs. These standards have been summarized as recommendations to PLTs and TAs and take into account all chapters of the WFME standards. Conclusion: The WFME standards selected here are recommended to PLTs and TAs in clinics and practices to achieve high-quality PGME. Empirical longitudinal studies will be required to examine both the implementation and the results of applying the modified WFME criteria in Germany.

Considering vocational training as selection criterion for medical students: evidence for predictive validity.

Prior work experience in a relevant medical profession is an important admission criterion currently used at many German medical schools in addition to cognitive criteria. In other countries, work experience is often considered in later admission stages (e.g., interviews with pre-selected subgroups of applicants). However, evidence for its predictive validity for study success in addition to cognitive admission criteria is currently lacking. We therefore assessed whether completed vocational training in a relevant medical profession can predict study performance in the first two years of study in addition to cognitive admission criteria. Admission and study performance data of all currently enrolled medical students at two German medical schools (Göttingen and Heidelberg) beginning with the 2013/14 cohort were retrospectively analyzed. Cognitive admission criteria in our sample were GPA grades and a cognitive test ("Test für Medizinische Studiengänge", TMS). We defined the study outcome parameter as the mean percentile rank over all performance data points over the first two years of study for each location, respectively. A multi-level model with varying intercepts by location, GPA, TMS, vocational training, and sex as predictors accounted for 14.5% of the variance in study outcome. A positive predictive association with study outcome was found for vocational training (ß = 0.33, p = .008) beyond GPA (ß = 0.38, p < .001) and TMS (ß = 0.26, p < .001). Our results support the use of prior vocational training as a selection criterion for medical studies potentially adding predictive validity to cognitive criteria.

Frequency of medical students' language expressing implicit uncertainty in simulated handovers.

OBJECTIVES: The aim of this study was to investigate the number and type of implicit expressions of uncertainty by medical students during simulated patient handovers. METHODS: Eighty-seven volunteer medical students, a convenience sample collected on a first-come, first-served basis, participated in simulated handovers. They each worked with three simulated patients who presented with different chief complaints and personal conditions. The handovers were video recorded and transcribed. A framework of implicit expressions of uncertainty was used to identify and count modifiers that attenuate or strengthen medical information using MAXQDA lexical search. We analysed the findings with respect to the patients' contexts. RESULTS: Implicit uncertainty expressions which attenuate or strengthen information occurred in almost equal frequency, 1879 (55%) versus 1505 (45%). Attenuators were found most frequently in the category 'Questionable', 1041 (55.4%), strengtheners in the category 'Focused', 1031 (68.5%). Most attenuators and strengtheners were found in the handover of two patients with challenging personal conditions ('angry man', 434 (23.1%) versus 323 (21.5%); 'unfocused woman', 354 (19.4%) versus 322 (21.4%)) and one patient with abnormal laboratory findings ('elevated creatinine', 379 (20.2%) versus 285 (18.9%)). CONCLUSIONS: Medical students use a variety of implicit expressions of uncertainty in simulated handovers. These findings provide an opportunity for medical educators to design communication courses that raise students' awareness for content-dependent implicit expressions of uncertainty and provide strategies to communicate uncertainty explicitly.

Evaluating the Global Rating scale's psychometric properties to assess communication skills of undergraduate medical students in video-recorded simulated patient encounters.

OBJECTIVES: To evaluate the psychometric properties of the Global Rating scale (GR) as an observer-based tool to assess communication skills of undergraduate medical students in video-recorded patient encounters. METHODS: Seventy advanced undergraduate medical students participated in a simulation-based assessment including patient consultations. Simulated patients rated these encounters with the Consultation and Relational Empathy (CARE) scale. Two independent, blinded raters assessed the videos of the encounters with the GR and another blinded rater with the Clinical Reasoning Indicators Scale (CRI-HT-S). To assess the GR's psychometric properties, we analysed reliability by means of a G-study, interrater reliability by ICC, convergent validity (correlation of GR and CARE), and divergent validity (correlation of GR and CRI-HT-S). RESULTS: We analysed 325 videos of 65 students (56.9% female, mean age 26.1 ± 2.2 years). The G-coefficient was.90. Interrater reliability of the GR was ICC = .95, 95% CI [.91,.97]. CARE and GR correlated moderately (ρ = .47, 95% CI [.25,.65]). GR and CRI-HT-S did not correlate (ρ = .09, 95% CI [-.16,.34]). CONCLUSIONS: With excellent reliability and adequate validity, the quality of the GR as assessment instrument for communication skills could be demonstrated. PRACTICE IMPLICATIONS: The GR is a suitable instrument for video-based rating of communication skills.

Validation of the ComCare index for rater-based assessment of medical communication and interpersonal skills.

OBJECTIVES: To develop and validate a short instrument to assess undergraduate medical students' communication and interpersonal skills in videographed history taking situations with simulated patients. METHODS: Sixty-seven undergraduate medical students participating in an assessment including videographed physician-patient encounters for history taking with five simulated patients were included in this study. The last video of each participant's consultation hour was rated by two independent assessors with the eight-item ComCare index for assessment of communication and interpersonal skills newly designed for the external rater perspective (ComCareR). We compared the sum scores of the ComCareR with ratings of the same videos with the Kalamazoo Communication Skills Assessment Form from an observational perspective (KCSAFd-video) and the Global Rating scale (GR), which also measure communication and interpersonal skills. RESULTS: The ComCareR showed an excellent interrater reliability (ICC = .85). We found a small but significant correlation with the KCSAFd-video Interpersonal Competence (ρ = .34, 95% CI [.10,.54]) and a high positive correlation with the GR (ρ = .59, 95% CI [.40,.73]). CONCLUSIONS: The ComCareR is a valid and brief index for holistic assessment of communication and interpersonal skills in physician-patient encounters. PRACTICE IMPLICATIONS: The ComCareR can be used for quick rater-based assessment of physicians' communication and interpersonal skills.

It does not have to be either or! Assessing competence in medicine should be a continuum between an analytic and a holistic approach.

Assessing competence is a tremendous challenge in medical education. There are two contrasting approaches in competence assessment: an analytic approach that aims to precisely measure observable constituents and facets of competence and a holistic approach that focuses on a comprehensive assessment of competences in complex real situations reflecting actual performance. We would like to contribute to the existing discourse about medical competence and its assessment by proposing an approach that can provide orientation for the development of competence-based assessment concepts in undergraduate and postgraduate medical education. The approach follows Kane's framework of an "argument-based approach" to validity and is based on insights into task complexity, testing and learning theories as well as the importance of the learning environment. It describes a continuum from analytic to holistic approaches to assess the constituents and facets of competence to performance. We conclude that the complexity of a task should determine the selection of the assessment and suggest to use this approach to reorganize and adapt competence assessment.

Assessing clinical reasoning in undergraduate medical students during history taking with an empirically derived scale for clinical reasoning indicators.

BACKGROUND: The clinical reasoning process, which requires biomedical knowledge, knowledge about problem-solving strategies, and knowledge about reasons for diagnostic procedures, is a key element of physicians' daily practice but difficult to assess. The aim of this study was to empirically develop a Clinical Reasoning Indicators-History Taking-Scale (CRI-HT-S) and to assess the clinical reasoning ability of advanced medical students during a simulation involving history taking. METHODS: The Clinical Reasoning Indictors-History Taking-Scale (CRI-HT-S) including a 5-point Likert scale for assessment was designed from clinical reasoning indicators identified in a qualitative study in 2017. To assess indicators of clinical reasoning ability, 65 advanced medical students (semester 10, n = 25 versus final year, n = 40) from three medical schools participated in a 360-degree competence assessment in the role of beginning residents during a simulated first workday in hospital. This assessment included a consultation hour with five simulated patients which was videotaped. Videos of 325 patient consultations were assessed using the CRI-HT-S. A factor analysis was conducted and the students' results were compared according to their advancement in undergraduate medical training. RESULTS: The clinical reasoning indicators of the CRI-HT-S loaded on three factors relevant for clinical reasoning: 1) focusing questions, 2) creating context, and 3) securing information. Students reached significantly different scores (p < .001) for the three factors (factor 1: 4.07 ± .47, factor 2: 3.72 ± .43, factor 3: 2.79 ± .83). Students in semester 10 reached significantly lower scores for factor 3 than students in their final year (p < .05). CONCLUSIONS: The newly developed CRI-HT-S worked well for quantitative assessment of clinical reasoning indicators during history taking. Its three-factored structure helped to explore different aspects of clinical reasoning. Whether the CRI-HT-S has the potential to be used as a scale in objective structured clinical examinations (OCSEs) or in workplace-based assessments of clinical reasoning has to be investigated in further studies with larger student cohorts.

Standardized examinees: development of a new tool to evaluate factors influencing OSCE scores and to train examiners.

Introduction: The Objective Structured Clinical Examination (OSCE) is an established format for practical clinical assessments at most medical schools and discussion is underway in Germany to make it part of future state medical exams. Examiner behavior that influences assessment results is described. Erroneous assessments of student performance can result, for instance, from systematic leniency, inconsistent grading, halo effects, and even a lack of differentiation between the tasks to be performed over the entire grading scale. The aim of this study was to develop a quality assurance tool that can monitor factors influencing grading in a real OSCE and enable targeted training of examiners. Material, Methods and Students: Twelve students at the Medical Faculty of the University of Heidelberg were each trained to perform a defined task for a particular surgical OSCE station. Definitions were set and operationalized for an excellent and a borderline performance. In a simulated OSCE during the first part of the study, the standardized student performances were assessed and graded by different examiners three times in succession; video recordings were made. Quantitative and qualitative analysis of the videos was also undertaken by the study coordinator. In the second part of the study, the videos were used to investigate the examiners' acceptance of standardized examinees and to analyze potential influences on scoring that stemmed from the examiners' experience. Results: In the first part of the study, the OSCE scores and subsequent video analysis showed that standardization for defined performance levels at different OSCE stations is generally possible. Individual deviations from the prescribed examinee responses were observed and occurred primarily with increased complexity of OSCE station content. In the second part of the study, inexperienced examiners assessed a borderline performance significantly lower than their experienced colleagues (13.50 vs. 15.15, p=0.035). No difference was seen in the evaluation of the excellent examinees. Both groups of examiners graded the item "ocial competence" - despite identical standardization - significantly lower for examinees with borderline performances than for excellent examinees (4.13 vs. 4.80, p<0.001). Conclusion: Standardization of examinees for previously defined performance levels is possible, making a new tool available in future not only for OSCE quality assurance, but also for training examiners. Detailed preparation of the OSCE checklists and intensive training of the examinees are essential. This new tool takes on a special importance if standardized OSCEs are integrated into state medical exams and, as such, become high-stakes assessments.

Entrustable professional activities and facets of competence in a simulated workplace-based assessment for advanced medical students.

Background: Competence-based assessment formats in medical education usually focus on individual facets of competence (FOCs). The concept of 'Entrustable Professional Activities' (EPAs) encompasses supervisors' decisions on which level of supervision a trainee requires to perform a professional activity including several FOCs. How the different FOCs as perceived by clinician raters contribute to entrustment decisions is yet unclear.Objective: How do FOC perceptions relate to entrustment-decisions?Methods: Sixty-seven advanced medical students participated in an assessment simulating the first day of a resident physician. Participants were rated by supervisors for seven FOCs and twelve EPAs.Results: There was a positive correlation between FOC and EPA scores. Each EPA displayed a different correlation pattern with FOC ratings.Discussion: For most EPAs high levels of entrustment were associated with high ratings for selected FOCs. The results are in alignment with the assumption that each EPA encompasses a different set of FOCs.Conclusions: In our simulated workplace-based assessment, entrustment decisions for EPAs reflect the FOCs observed in a trainee. Thus, assessment of FOCs alongside with EPA ratings could add to the understanding of factors contributing to entrustment decisions.

Implicit expression of uncertainty - suggestion of an empirically derived framework.

BACKGROUND: Uncertainty occurs in physicians' daily work in almost every clinical context and is also present in the clinical reasoning process. The way physicians communicate uncertainty in their thinking process during handoffs is crucial for patient safety because uncertainty has diverse effects on individuals involved in patient care. Dealing with uncertainty and expressing uncertainty are important processes in the development of professional identity of undergraduate medical students. Many studies focused on how to deal with uncertainty and whether uncertainty is explicitly expressed. Hardly any research has been done regarding implicit expression of uncertainty. Therefore, we studied the ways in which medical students in the role of beginning residents implicitly express uncertainty during simulated handoffs. METHODS: Sixty-seven advanced undergraduate medical students participated in a simulated first day of residency including a consultation hour, a patient management phase with interprofessional interaction, and a patient handoff. We transcribed the videographed handoffs verbatim and extracted language with respect to expression of uncertainty using a grounded theory approach. Text sequences expressing patient related information were analyzed and coded with respect to language aspects which implicitly modified plain information with respect to increasing or decreasing uncertainty. Concepts and categories were developed and discussed until saturation of all aspects was reached. RESULTS: We discovered a framework of implicit expressions of uncertainty regarding diagnostic and treatment-related decisions within four categories: "Statement", "Assessment", "Consideration", and "Implication". Each category was related to either the subcategory "Actions" or "Results" within the diagnostic or therapeutic decisions. Within each category and subcategory, we found a subset of expressions, which implicitly attenuated or strengthened plain information thereby increasing uncertainty or certainty, respectively. Language that implicitly attenuated plain information belonged to the categories questionable, incomplete, alterable, and unreliable while we could ascribe implicit strengtheners to the categories assertive, adequate, focused, and reliable. CONCLUSIONS: Our suggested framework of implicit expression of uncertainty may help to raise the awareness for expression of uncertainty in the clinical reasoning process and provide support for making uncertainty explicit in the teaching process. This may lead to more transparent communication processes among health care professionals and eventually to improved patient safety.

Validation of a competence-based assessment of medical students' performance in the physician's role.

BACKGROUND: Assessing competence of advanced undergraduate medical students based on performance in the clinical context is the ultimate, yet challenging goal for medical educators to provide constructive alignment between undergraduate medical training and professional work of physicians. Therefore, we designed and validated a performance-based 360-degree assessment for competences of advanced undergraduate medical students. METHODS: This study was conducted in three steps: 1) Ten facets of competence considered to be most important for beginning residents were determined by a ranking study with 102 internists and 100 surgeons. 2) Based on these facets of competence we developed a 360-degree assessment simulating a first day of residency. Advanced undergraduate medical students (year 5 and 6) participated in the physician's role. Additionally knowledge was assessed by a multiple-choice test. The assessment was performed twice (t1 and t2) and included three phases: a consultation hour, a patient management phase, and a patient handover. Sixty-seven (t1) and eighty-nine (t2) undergraduate medical students participated. 3) The participants completed the Group Assessment of Performance (GAP)-test for flight school applicants to assess medical students' facets of competence in a non-medical context for validation purposes. We aimed to provide a validity argument for our newly designed assessment based on Messick's six aspects of validation: (1) content validity, (2) substantive/cognitive validity, (3) structural validity, (4) generalizability, (5) external validity, and (6) consequential validity. RESULTS: Our assessment proved to be well operationalised to enable undergraduate medical students to show their competences in performance on the higher levels of Bloom's taxonomy. Its generalisability was underscored by its authenticity in respect of workplace reality and its underlying facets of competence relevant for beginning residents. The moderate concordance with facets of competence of the validated GAP-test provides arguments of convergent validity for our assessment. Since five aspects of Messick's validation approach could be defended, our competence-based 360-degree assessment format shows good arguments for its validity. CONCLUSION: According to these validation arguments, our assessment instrument seems to be a good option to assess competence in advanced undergraduate medical students in a summative or formative way. Developments towards assessment of postgraduate medical trainees should be explored.

Implementing a logbook on entrustable professional activities in the final year of undergraduate medical education in Germany - a multicentric pilot study.

Objectives: The final year of undergraduate medical education (practical year) should foster the transition from undergraduate medical education to graduate medical education. Medical students in the practical year should be able to assume professional tasks, and supervisors should assign these tasks to them. In this pilot study, a curriculum based on the concept of entrustable professional activities (EPAs) was implemented and evaluated in the disciplines of internal medicine, surgery and general practice at four university hospitals. Methods:n=37 medical students and n=17 supervising physicians at four German university hospitals participated in the implementation study for one trimester. For evaluation purposes, we conducted focus group discussions and telephone interviews and analyzed them following qualitative content analysis. Results: We identified five different aspects as important for implementing the EPA curriculum in undergraduate medical education in the German context: Implementation process of the EPA curriculum and required resources, Entrustment process, Feedback sessions with supervisors, Students' and supervisors' role perceptionOverall impact of EPAs on training conditions in the practical year. Conclusion: The study presents a practical implementation of the EPA curriculum in Germany's undergraduate medical education. Besides the need for time and resources, the concept shows good feasibility and fosters a competence-oriented undergraduate medical education in the practical year.

Entrustable Professional Activities in final year undergraduate medical training - advancement of the final year training logbook in Germany.

Objective: Training in the final year (FY) of undergraduate medical training currently does not adequately prepare students for the independent performance of medical professional activities after graduation. The concept of Entrustable Professional Activities (EPA) offers the opportunity for a competency-based FY training with the focus on medical professional activities. Methodology: In regular meetings, the FY sub-working group of the German Medical Faculty Association (MFT), which includes representatives with clinical and didactic expertise of the Associations of Internal Medicine, Surgery and General Medicine, developed a concept for the competecy-orientated, EPA-based, FY model logbook 2.0. The selection of the units of practice was made in a cross-disciplinary, consensus-orientated discussion process based on the question which medical professional activities a young professional has to master in the inpatient or outpatient working environment. Results: For the FY electives internal medicine, surgery and general medicine, a blueprint of a total of 18 comprehensive, partially interdisciplinary EPAs relating to inpatient and outpatient care contexts were developed. Each EPA was operationalised by a short description, supervision levels were attributed, and the process of transparent entrustment was determined. Conclusions: The concept for a new FY model logbook 2.0 focuses on the interdisciplinary core medical professional activities in an inpatient and outpatient care context, in order to facilitate transition from undergraduate training to professional practice, and to help avoid overload, thus increasing patient safety.

Medical knowledge and teamwork predict the quality of case summary statements as an indicator of clinical reasoning in undergraduate medical students.

Background: Clinical reasoning refers to a thinking process including medical problem solving and medical decision making skills. Several studies have shown that the clinical reasoning process can be influenced by a number of factors, e.g. context or personality traits, and the results of this thinking process are expressed in case presentation. The aim of this study was to identify factors, which predict the quality of case summary statements as an indicator of clinical reasoning of undergraduate medical students in an assessment simulating the first day of residency. Methods: To investigate factors predicting aspects of clinical reasoning 67 advanced undergraduate medical students participated in the role of a beginning resident in our competence-based assessment, which included a consultation hour, a patient management phase, and a handover. Participants filled out a Post Encounter Form (PEF) to document their case summary statements and other aspects of clinical reasoning. After each phase, they filled out the Strain Perception Questionnaire (STRAIPER) to measure their situation dependent mental strain. To assess medical knowledge the participants completed a 100 questions multiple choice test. To measure stress resistance, adherence to procedures, and teamwork students took part in the Group Assessment of Performance (GAP) test for flight school applicants. These factors were included in a multiple linear regression analysis. Results: Medical knowledge and teamwork predicted the quality of case summary statements as an indicator of clinical reasoning of undergraduate medical students and explained approximately 20.3% of the variance. Neither age, gender, undergraduate curriculum, academic advancement nor high school grade point average of the medical students of our sample had an effect on their clinical reasoning skills. Conclusion: The quality of case summary statements as an indicator of clinical reasoning can be predicted in undergraduate medical students by their medical knowledge and teamwork. Students should be supported in developing abilities to work in a team and to acquire long term knowledge for good case summary statements as an important aspect of clinical reasoning.

[National Learning Objectives Catalogue in Surgery - General Part Defining Competences of Medical School Graduates in Surgery]. / Nationaler Kompetenzbasierter Lernzielkatalog Chirurgie ­ allgemeiner Teil mit fachbezogenen ärztlichen Handlungskompetenzen am Ende des Praktischen Jahres.

Competency-based medical education is needed in order to meet the requirements of medical care currently and in the future. The basis of this are activity-based learning objectives that are merged in competency-based catalogues. A basis for a core curriculum of undergraduate medical training is the National Catalogue of Learning Objectives for Undergraduate Medical Education (NKLM). Already in 2013, for surgery, the competencies which medical students should have achieved after completing the practical year (PJ) in relation to surgical diseases were defined in the special part of the National Catalogue of Learning Objectives in Surgery (NKLC). In the now amended general part of the NKLC, interdisciplinary competencies were defined and consented from all surgical disciplines, that are relevant for all surgical disciplines and that all representatives from the different surgical disciplines should incorporate in their surgical training. The complete NKLC is now available for faculties, teachers and students for trial (available online: https://www.dgch.de/index.php?id=190&L=528). The guiding principle for the entire development process was to make sure that students gain all competencies they need when starting to work as a medical doctor and therefor to increase patient safety.

[Position Paper of the Surgical Working Group for Teaching of the German Society of Surgery Regarding the "Master Plan 2020"]. / Positionspapier der chirurgischen Arbeitsgemeinschaft Lehre für die Deutsche Gesellschaft für Chirurgie zum "Masterplan Medizinstudium 2020".

The "Masterplan Medizinstudium 2020" from the German Federal Government should not be underestimated as only one among many announcement. Thus, the Surgical Working Group on Medical Education (CAL) of the German Association of Surgeons (DGCH) comments on the intended measures of the "Masterplan Medizinstudium 2020" and discusses the challenges, consequences and duties arising from the "Masterplan Medizinstudium 2020" for the representatives of the surgical societies and those engaged in surgical undergraduate training.