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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

[National Learning Objectives Catalogue in Surgery - General Part Defining Competences of Medical School Graduates in Surgery]

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.

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.

German Language Adaptation of the Kalamazoo Communication Skills Assessment Form (KCSAF): A Multi-Method Study of Two Cohorts of Medical Students

Abstract. This work investigates the German version of the Kalamazoo Communication Skills Assessment Form (KCSAFd) for three assessment methods: students' self-assessment (KCSAFd-self), assessment by standardised patients (KCSAFd-sPat) and video-assessment by trained raters (KCSAFd-video). Videotaped simulated patient consultations of N = 163 medical students from the first ( n = 97) and the final clinical years ( n = 66) were rated using the KCSAFd. Investigating the psychometric properties of the instrument, we found a two factor-construct with interpersonal and conversational competence. All methods showed good internal consistency and acceptable model fit values. Additionally, we found plausible relationships between the three methods and meaningful differences between the two groups of students.

[Position Paper of the Surgical Working Group for Teaching of the German Society of Surgery Regarding the "Master Plan 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.

[Selection of medical students : Measurement of cognitive abilities and psychosocial competencies]

The German Constitutional Court is currently reviewing whether the actual study admission process in medicine is compatible with the constitutional right of freedom of profession, since applicants without an excellent GPA usually have to wait for seven years. If the admission system is changed, politicians would like to increase the influence of psychosocial criteria on selection as specified by the Masterplan Medizinstudium 2020.What experiences have been made with the actual selection procedures? How could Situational Judgement Tests contribute to the validity of future selection procedures to German medical schools?High school GPA is the best predictor of study performance, but is more and more under discussion due to the lack of comparability between states and schools and the growing number of applicants with top grades. Aptitude and knowledge tests, especially in the natural sciences, show incremental validity in predicting study performance. The measurement of psychosocial competencies with traditional interviews shows rather low reliability and validity. The more reliable multiple mini-interviews are superior in predicting practical study performance. Situational judgement tests (SJTs) used abroad are regarded as reliable and valid; the correlation of a German SJT piloted in Hamburg with the multiple mini-interview is cautiously encouraging.A model proposed by the Medizinischer Fakultätentag and the Bundesvertretung der Medizinstudierenden considers these results. Student selection is proposed to be based on a combination of high school GPA (40%) and a cognitive test (40%) as well as an SJT (10%) and job experience (10%). Furthermore, the faculties still have the option to carry out specific selection procedures.

Train-the-Trainer: Professionalisierung der Lehre im klinischen Alltag – Selbsteinschätzung Lehrender zur didaktischen Kompetenz und den Rahmenbedingungen des Unterrichts

Hintergrund Didaktiktrainings tragen zur Verbesserung der Qualität der medizinischen Lehre bei. In einem Kurs des Train-the-Trainer-Konzepts (TTT-Konzepts) der Chirurgischen Arbeitsgemeinschaft Lehre (CAL) wurden dabei Lehrende (TN) verschiedener Professionen und Karrierestufen gemeinsam unterrichtet.

Ziel der Arbeit Einschätzungen zur eigenen Lehrtätigkeit im klinischen Alltag durch verschiedene Gruppen, wie assistenzärztliches (AÄ), oberärztliches Personal (OÄ) und Pflegende (KP), deren Wahrnehmung von Erschwernissen und Artikulation von Wünschen zur Lehrverbesserung.

Material und Methoden Vor Kursbeginn wurden biografische Daten, didaktische Vorerfahrungen, Lehrhindernisse sowie Wünsche zur Lehrverbesserung erfragt. Nach Abschluss wurden die TN gebeten, den Kurs zu bewerten. Die Antworten zu den geschlossenen und offenen Fragen wurden quantitativ und qualitativ ausgewertet.

Ergebnisse Von 2014 bis 2017 wurden 6 Basiskurse (TTT-A) an 3 Standorten durchgeführt. 97 TN nahmen an den Befragungen teil (AÄ n = 44, OÄ n = 19, KP n = 17). Mehr als ⅔ verfügten bereits über didaktische Vorkenntnisse. Zwischen ärztlichen und pflegerischen Berufsgruppen fanden sich hierbei keine signifikanten Unterschiede. Während AÄ und KP primär am Krankenbett unterrichteten, lehrten OÄ überwiegend im Rahmen von Vorlesungen, Wahlfächern und Seminaren. Für die Lehre im klinischen Alltag fühlte sich nur ein geringer Anteil aus allen Berufsgruppen gut vorbereitet. Als Haupterschwernisse wurden Zeit- und Personalmangel, eine zu hohe Anzahl von Studierenden und zu geringe eigene didaktische Vorkenntnisse angegeben. Fast ⅔ der AÄ empfanden die studentische Lehre als starke oder moderate Belastung, gegenüber ca. 50% der OÄ und 60% KP. Als Wünsche zur Lehrverbesserung wurden differenziertere Vorgaben zu Inhalt und Aufbau der Lehrveranstaltungen, eine höhere Wertschätzung der Lehre insgesamt sowie die regelmäßige didaktische Qualifizierung der Lehrenden genannt.

Diskussion Berufsgruppenbedingte Unterschiede im klinischen Alltag und individueller Karrierefortschritt üben einen Einfluss auf Art, Umsetzung und Wahrnehmung der Lehrtätigkeit aus. Durch Fokussierung auf Lernziele und wesentliche für den Unterricht am Krankenbett relevante Lehr- und Prüfungsformate können Dozententrainingsprogramme berufsgruppenübergreifend zum Wissens- und Kompetenzzuwachs beitragen. Hinweise auf einen nachhaltigen Effekt ermutigen zur Fortsetzung und Weiterentwicklung des TTT-Konzepts.

Interprofessional assessment of medical students' competences with an instrument suitable for physicians and nurses

BACKGROUND

Physicians need a set of specific competences to perform well in interprofessional teams in their first year of residency. These competences should be achieved with graduation from medical school. Assessments during undergraduate medical studies are mostly rated by supervisors only. The aim of our study was to compare the rating of core facets of competence of medical students late in their undergraduate training as well as the rating confidence between three different groups of assessors (supervisors, residents, and nurses) in an assessment simulating the first day of residency.

METHODS

Sixty-seven advanced medical students from three different medical schools (Hamburg, Oldenburg and Munich) participated in a 360-degree assessment simulating the first working day of a resident. Each participant was rated by three assessors - a supervisor, a resident and a nurse - in seven facets of competence relevant for the first year of residency: (1) responsibility, (2) teamwork and collegiality, (3) knowing and maintaining own personal bounds and possibilities, (4) structure, work planning and priorities, (5) coping with mistakes, (6) scientifically and empirically grounded method of working, and (7) verbal communication with colleagues and supervisors. Means of all assessed competences and confidences of judgement of the three rating groups were compared. Additionally, correlations between assessed competences and confidence of judgement within each group of raters were computed.

RESULTS

All rating groups showed consistent assessment decisions (Cronbach's α: supervisors = .90, residents = .80, nurses = .78). Nurses assessed the participants significantly higher in all competences compared to supervisors and residents (all p ≤ .05) with moderate and high effect sizes (d = .667-1.068). While supervisors' and residents' ratings were highest for "teamwork and collegiality", participants received the highest rating by nurses for "responsibility". Competences assessed by nurses were strongly positively correlated with their confidence of judgment while supervisors' assessments correlated only moderately with their confidence of judgment in two competences.

CONCLUSIONS

Different professional perspectives provide differentiated competence ratings for medical students in the role of a beginning resident. Rating confidence should be enhanced by empirically derived behavior checklists with anchors, which need to be included in rater training to decrease raters' subjectivity.

Functional outcome after pouch-anal reconstruction with primary and secondary mucosectomy for patients with familial adenomatous polyposis (FAP)

INTRODUCTION

Restorative proctocolectomy and ileal pouch-anal reconstruction is the surgical standard for the majority of patients with familial adenomatous polyposis (FAP). The pouch-anal anastomosis may be performed handsewn after primary mucosectomy or by double stapling. Better functional results favour the latter; however, higher rates of remaining rectal mucosa with adenomas often necessitate secondary mucosectomy. Data on functional outcome after secondary mucosectomy is scarce. The aim of the study was to analyse whether patients who undergo secondary mucosectomy maintain their functional benefits compared to patients with primary mucosectomy.

PATIENTS AND METHODS

Twenty patients after secondary mucosectomy and 31 patients after primary mucosectomy were compared with respect to their functional outcome, using the MSKCC score, the Wexner score and ano-rectal physiology testing.

RESULTS

The MSKCC global score and the Wexner score showed a non-significant trend towards slightly better results after secondary mucosectomy (63.1 vs. 56.6, p = 0.0188 and 9.5 vs. 11, p = 0.3780). Patients after secondary mucosectomy also showed a tendency towards less bowel movements per 24 h (7 (range 4-11) vs. 8.5 (range 3-20), p = 0.1518). Resting pressures were slightly higher after secondary (44 vs. 39.6 mmHg, p = 0.4545) and squeeze pressures slightly higher after primary mucosectomy (87.6 vs. 81.2 mmHg, p = 0.6126). However, the results did not reach statistical significance.

CONCLUSION

The results of this study cannot ultimately resolve the controversy concerning handsewn versus stapled ileal pouch-anal anastomosis. Our results suggest a trend towards better functional results after stapled anastomosis with secondary mucosectomy.

Assessing core competences of medical students with a test for flight school applicants

BACKGROUND

Important competences of physicians regarding patient safety include communication, leadership, stress resistance, adherence to procedures, awareness, and teamwork. Similarly, while selected, prospective flight school applicants are tested for the same set of skills. The aim of our study was to assess these core competences in advanced undergraduate medical students from different medical schools.

METHODS

In 2017, 67 medical students (year 5 and 6) from the universities of Hamburg, Oldenburg, and TU Munich, Germany, participated in the verified Group Assessment Performance (GAP)-Test at the German Aerospace Center (DLR) in Hamburg. All participants were rated by DLR assessment observers with a set of empirically derived behavioural checklists. This lists consisted of 6-point rating scales (1: very low occurrence to 6: very high occurrence) and included the competences leadership, teamwork, stress resistance, communication, awareness, and adherence to procedures. Medical students' scores were compared with the results of 117 admitted flight school applicants.

RESULTS

Medical students showed significantly higher scores than admitted flight school applicants for adherence to procedures (p < .001, d = .63) and communication (p < .01, d = .62). They reached significantly lower ratings for teamwork (p < .001, d = .77), stress resistance (p < 0.001, d = .70), and awareness (p < .001, d = 1.31). Students in semester 10 showed significantly (p < .02, d = .58) higher scores in domain awareness compared to the final year students. On average, flight school entrance level was not reached by either group for this domain.

CONCLUSIONS

Advanced medical students' low results for awareness are alarming as awareness is essential and integrative for clinical reasoning and patient safety. Further studies should elucidate and discuss whether awareness needs to be included in medical student selection or integrated into the curriculum in training units.

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.

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.

Perceived strain of undergraduate medical students during a simulated first day of residency

BACKGROUND

Residents face demanding situations on the job and have been found to perceive high levels of strain. Medical students also reported a high degree of strain and even depressive tendencies when entering their clinical rotations. The aim of this study was to explore the perceived strain of medical students from different undergraduate curricula and at different stages of academic advancement during different phases of an assessment simulating a resident's first day in hospital.

METHODS

Sixty-seven undergraduate medical students participated in the following three phases of the assessment in the role of a resident: a consultation hour with five simulated patients, a management phase with interprofessional contact, and a patient handover with a colleague. They completed the Strain Perception Questionnaire (STRAIPER) after each phase. Students from different undergraduate curricula (VI: vertically integrated, n = 35 versus non-VI: not vertically integrated, n = 26) and different academic advancement (semester 10, n = 26 versus final year, n = 41) were compared.

RESULTS

All students showed the highest strain level after the management phase compared to the consultation hour and the handover. Medical students from a non-VI curriculum felt significantly more strain in the dimension of agitation (p < .05) after the consultation hour compared to students from a VI curriculum and compared to the management phase and the handover. No significant difference in perceived strain was found between students from semester 10 compared to final year students.

CONCLUSIONS

During the consultation hour and the handover with a colleague medical students faced tasks which are familiar to them from undergraduate education. Their higher strain levels during the management phase might occur because they are confronted with unfamiliar tasks and decisions. Feeling responsible for the right actions in this phase of multitasking and professional interaction might have added to the strain students perceived during this phase. Patient management should be emphasized more in any type of undergraduate medical curriculum.

[Hospital nurses' perspective on academic nursing education: a cross-sectional study in hospitals in the northwestern part of Germany]

Hospital nurses' perspective on academic nursing education: a cross-sectional study in hospitals in the northwestern part of Germany Abstract.

BACKGROUND

Currently, there is an increasing need for highly qualified nurses in Germany. Against this background, an academic nursing education is frequently demanded in order to meet the high level of competences nurses must fulfil.

AIM

This cross-sectional study aimed to explore nurses' attitudes towards academic nursing education as well as their self-reported scientific competences.

METHODS

Based on a standardized questionnaire, we surveyed 547 hospital nurses from six different hospitals in the northwestern part of Germany. By means of a bivariate analysis and two multivariate regression models, we examined the influence of the independent variables "professional position", "degree of academic education", "age" and "gender" on the dependent variables "attitude towards academic nursing education" and "scientific competences". The multivariate analysis included three co-variates analysing different ways of support of academic nursing education within the hospitals.

RESULTS

Especially nursing staff who has completed a study programme, is currently studying or hold executive positions has a more positive attitude towards academic education than its colleagues have. Moreover, opportunities for advancement within the hospitals influence the staff's attitude positively. With regard to the assessment of scientific competences, the analysis shows that a completed or currently conducted study programme as well as an executive position have a positive influence. In addition, male nursing staff, young nursing staff and staff with access to scientific articles assess their scientific skills more positively than their colleagues do.

CONCLUSIONS

The attitudes towards academic education are still heterogeneous and influenced by different factors. Accordingly, the worth of academic education needs to be demonstrated.

Pilot evaluation of an objective structured assessment of technical skills tool for chest tube insertion

Background: Chest tube insertion is a standard intervention for management of various injuries of the thorax. Efficient clinical training of this and similar bed-side procedures is equally demanded and improvable. Here, we propose a nouveau means of assessment and feedback using an Objective Structured Assessment of Technical Skills (OSATS) tool. The modified OSATS for chest drain insertion is evaluated in a pilot trial focusing on chest drain insertion. Methods: Participants in the pilot trial were medical students (3^rd-6^th year of studies, n=9), junior residents (1^st-3^rd post-graduate year, n=12), senior residents (4^th-6^th post-graduate year, n=14), and attending surgeons (n=6) from Heidelberg University. Chest drain insertions on a cadaveric porcine model were rated by experts with the modified OSATS score. Participants' performances were videotaped and subsequently rated by two remote experts (video rating). Primary aim was to assess criterion validity of the OSATS to distinguish experience levels. Results: Kruskal-Wallis test showed significant differences between means of scores between four groups stratified by previous experience in chest tube insertion (level 0: 22.1±3.2 vs. level 1: 26.8±2.8 vs. level 2: 35.4±2.2 vs. level 3: 41.0±2.0; p=0.002; p_1,3=0.049, p_0,3=0.005). However, if groups were stratified by formal professional level, no statistically significant distinction could be made using OSATS. Hence, the OSATS tool showed criterion validity for differentiation between experience levels. Conclusion: In the pilot study, the modified OSATS for chest tube insertion was apt to standardize expert rating and could be used to measure skill and to depict different experience levels. The OSATS will help facilitate training and assessment of chest drain insertion and could therefore improve surgical training for trauma situations. According to our data, the OSATS might be integrated into modern curricula.

Risk Factors Associated With Pouch Adenomas in Patients With Familial Adenomatous Polyposis

BACKGROUND

Restorative proctocolectomy with ileal pouch-anal reconstruction is the standard prophylactic surgical procedure for patients with familial adenomatous polyposis. However, several groups have reported the development of adenomas and even carcinomas within the ileal pouch. The predisposing factor was the time interval after pouch surgery in some studies, but it was the severity of the initial colonic disease and duodenal adenomatosis in others.

OBJECTIVE

The aim of this study was to further clarify the prevalence of pouch adenomas, clinical risk factors, and a possible phenotype-genotype relation in a large population of patients with familial adenomatous polyposis, as well as to analyze pouch adenoma-free survival.

DESIGN

This study was designed as a cohort study.

SETTINGS

This study was conducted in a specialized outpatient clinic at the University of Heidelberg.

PATIENTS

A total of 192 patients with familial adenomatous polyposis were included, and all of the available endoscopy reports after pouch surgery were screened for pouch adenomas. Additional clinical information was retrieved from the Heidelberg Polyposis Register.

MAIN OUTCOME MEASURES

This present study revealed 3 main independent risk factors for the development of pouch adenomas: age <18 years at the time of IPAA, male sex, and the presence of gastric adenomas. Secondary outcome measures were adenoma progression and overall pouch adenoma-free survival.

RESULTS

Pouch adenomas were detected in 46.9% of patients. Median follow-up was 12.8 years (interquartile range, 9.0-17.0 y) for patients with pouch adenomas and 7.3 years (interquartile range, 2.5-12.2 y) for those without them. Patients underwent pouch surgery at a median age of 27.5 years (range, 10.2-58.5 y), and pouch adenomas occurred a median of 8.5 years (range, 0.9-25.1 y) after surgery. Also detected were gastric adenomas in 37.2%, duodenal adenomas in 80.3%, and desmoid tumors in 24.5% of patients. Estimation of pouch adenoma-free survival revealed that, after 20 years, only ≈22% of patients would be free of pouch adenomas. Male sex, age ≦18 years at the time of pouch surgery, and gastric adenomas were found to be independent risk factors for the development of pouch adenomas in a multivariate Cox regression analysis (p = 0.0002, p = 0.0059, and p = 0.0020). No predisposing germline mutation for pouch adenoma development was detected.

LIMITATIONS

Detailed information on the initial preoperative findings was not fully available, and the study was only carried out as a single-center study.

CONCLUSIONS

A severe upper intestinal phenotype, male sex, and age <18 years at the time of IPAA all increase the risk for development of pouch adenomas. See Video Abstract at http://links.lww.com/DCR/A675.

"Heidelberg Standard Examination" - Final year students' experiences with a handbook and instructional videos to improve medical competence in conducting physical examinations

Background: The physical examination (PE) of patients is a core competence in almost all medical disciplines. The teaching materials "Heidelberger Standard Examination", consisting of a handbook and accompanying videos, were developed with the objective of providing medical students with an innovative faculty-wide teaching and examination standard to sustainably advance students' PE competences during medical training. Methods: In a "mixed-method approach" comprising both quantitative and qualitative measures, our study examined Heidelberg University Hospital final year (FY) medical students' use and evaluation of the individual teaching material components. Therefore, 92 FY students completed quantitative evaluation measures and ten FY students took part in individual 30-minute semi-structured interviews. Results: Of the sample of n=77 students, who had completed the clinical part of their studies at Heidelberg University Hospital, 97.4% (n=75) had used the handbook and 35.0% (n=27) the accompanying videos. The teaching materials were evaluated via the common German six-point school grading system with an average mark of 1.35±0.5 for the handbook and a mark of 2.15±1.0 for the accompanying videos. Further, our results show that FY students especially valued the "Heidelberg Standard Examination" handbook as a guide and general reference work and felt the materials improved their self-perceived PE competence. Although FY students saw the accompanying video material as helpful, it was less frequently used, indicating further development potential. Overall, results reveal that FY students perceive the "Heidelberg Standard Examination" teaching program to contribute to the improvement of the quality of their PE training.

Identifying low test-taking effort during low-stakes tests with the new Test-taking Effort Short Scale (TESS) - development and psychometrics

BACKGROUND

Low-stakes tests are becoming increasingly important in international assessments of educational progress, and the validity of these results is essential especially as these results are often used for benchmarking. Test scores in these tests not only mirror students' ability but also depend on their test-taking effort. One way to obtain more valid scores from participating samples is to identify test-takers with low test-taking effort and to exclude them from further analyses. Self-assessment is a convenient and quick way of measuring test-taking effort. We present the newly developed Test-taking Effort Short Scale (TESS), which comprises three items measuring attainment value/intrinsic value, utility value, and perceived benefits, respectively.

METHODS

In a multicenter validation study with N = 1837 medical students sitting a low-stakes progress test we analyzed item and test statistics including construct and external validity.

RESULTS

TESS showed very good psychometric properties. We propose an approach using stanine norms to determine a cutoff value for identifying participants with low test-taking effort.

CONCLUSION

With just three items, TESS is shorter than most established self-assessment scales; it is thus suited for administration after low-stakes progress testing. However, further studies are necessary to establish its suitability for routine usage in assessment outside progress testing.

Die Wertigkeit des gemeinsamen Faches Orthopädie-Unfallchirurgie im 2. Staatsexamen – Vergleich der schriftlichen 2. Staatsexamina mit dem Nationalen Kompetenzbasierten Lernzielkatalog Chirurgie

Hintergrund Der Nationale Kompetenzbasierte Lernzielkatalog Chirurgie (NKLC) definiert für jedes seiner 230 Lernziele eine Kompetenzebene von „Kompetenzebene 1: Faktenwissen“ bis zu „Kompetenzebene 3: selbstständiges Handeln“. Trotz des erwiesenen Einflusses von summativen Prüfungen auf das Lernverhalten von Studierenden bilden diese Lernziele nicht die Grundlage für das 2. Staatsexamen. Die vorliegende Studie untersucht, inwiefern die Prüfungsfragen des 2. Staatsexamens bereits die orthopädisch-unfallchirurgischen Lernziele des NKLC adressieren und welche thematische Schwerpunktsetzung hierbei erfolgt.

Material und Methoden Es erfolgte eine retrospektive Analyse basierend auf den Examensfragen von Herbst (H) 2009 bis Herbst 2014 (n = 11). Zunächst wurden im NKLC durch 5 Ober- und Fachärzte die Lernziele aus den Bereichen Orthopädie und Unfallchirurgie identifiziert. Nachfolgend wurden aus den 11 untersuchten Staatsexamina die Fragen definiert, die sich auf die orthopädisch-unfallchirurgischen Lernziele bezogen. Analysiert wurden die Gesamtzahl der Fragen, die Anzahl der Fragen pro Examen sowie pro Lernziel und Kompetenzebene.

Ergebnisse Insgesamt konnten 113 Lernziele des NKLC (entspricht 49,1% aller Lernziele des NKLC) dem Fach Orthopädie und Unfallchirurgie zugeordnet werden. Im Studienzeitraum adressierten 543 Fragen diese 113 Lernziele (entspricht 15,6% aller 3480 Fragen). Pro Examen konnten durchschnittlich 49,36 ± 14,1 (Min. 30; Max. 80) Fragen mit Bezug zu Orthopädie und Unfallchirurgie identifiziert werden. Insgesamt wurden 13,45 ± 6,39 (Min. 6; Max. 24) Fragen zu Lernzielen (LZ) der Kompetenzebene 3a und b, 21,45 ± 9,94 (Min. 9; Max. 39) Fragen zu LZ der Kompetenzebene 2 und 14,45 ± 6,36 (Min. 6; Max. 25) Fragen zu LZ der Kompetenzebene 1 gestellt. Die Mehrheit der Fragen adressierten „Erkrankungen des rheumatischen Formenkreises“ (n = 16 im Herbst 2009).

Schlussfolgerung Die Anzahl der Fragen mit unfallchirurgisch-orthopädischem Schwerpunkt im 2. Staatsexamen erscheint in Relation zur Gesamtzahl aller gestellten Fragen ausreichend hoch. Allerdings liegt eine thematische Imbalance vor, und gerade klinisch wichtige Lernziele mit hoher Kompetenzebene werden nicht ausreichend häufig geprüft. Eine bessere Abstimmung der Staatsprüfung mit den Lernzielkatalogen ist erforderlich.

Medizinische Prüfung zwischen Wunsch und Wirklichkeit – Analyse der Übereinstimmung zwischen dem 2. Abschnitt der ärztlichen Prüfung und dem Nationalen Kompetenzbasierten Lernzielkatalog Chirurgie

Hintergrund Die Chirurgische Arbeitsgemeinschaft Lehre der Deutschen Gesellschaft für Chirurgie (CAL) hat den Nationalen Kompetenzbasierten Lernzielkatalog Chirurgie (NKLC) entwickelt. Der NKLC definiert für jedes der 230 Lernziele eine Kompetenzebene (KE) von „KE 1: Faktenwissen“ bis zu „KE 3: selbstständige Handlung“. Die vorliegende Studie untersucht, inwiefern sich die Prüfungsfragen des 2.Staatsexamens mit den Lernzielen des NKLC decken und welche thematische Gewichtung dabei vom Institut für Medizinische und Pharmazeutische Prüfungsfragen (IMPP) vorgenommen wurde.

Material und Methoden Zunächst wurden ein Leitfaden und ein Auswertungsbogen entwickelt, um die standardisierte Zuordnung und Dokumentation einzelner Prüfungsfragen des 2. Staatexamens zu Lernzielen des NKLC zu ermöglichen. In einer retrospektiven Analyse wurden dann 11 Staatsexamina (Herbst 2009 bis Herbst 2014) von mindestens 3 Reviewern unabhängig voneinander analysiert. Die Chirurgie-Fragen wurden identifiziert und einem Lernziel des NKLC zugeordnet. In die Analyse gingen die Anzahl der chirurgischen Lernziele sowie die Anzahl der chirurgischen Fragen pro Examen, pro Lernziel und pro festgelegte KE ein.

Ergebnisse Es analysierten 13 Reviewer aus 6 chirurgischen Disziplinen. Durchschnittlich wurden 79,1% aller 3480 Fragen aus 11 Examina übereinstimmend als chirurgisch oder nicht chirurgisch gewertet. Pro Examen (aus je max. 320 Fragen) wurden 98,8 ± 22,6 Fragen (Min.: 69, Max.: 150) als chirurgisch eingestuft. Pro Lernziel wurden 2,2 ± 0,3 Fragen (Min.: 1, Max.: 16) gestellt. Pro Examen wurden 23,5 ± 6,3 Fragen (Min.: 11; Max.: 31) zu Lernzielen mit der KE 3 (selbstständige Durchführung), 52,5 ± 16,7 (Min.: 34; Max.: 94) zu Lernzielen mit KE 2 (Anwendungs- und Entscheidungswissen) und 22,8 ± 7,7 Fragen (Min.: 9; Max.: 34) zu Lernzielen mit KE 1 (reines Faktenwissen) pro Examen gestellt. 64 Lernziele (27,8% der insgesamt 230 Lernziele des NKLC) wurden gar nicht geprüft. Das am häufigste geprüfte chirurgische Lernziel stammte mit 70 Fragen aus dem Bereich „Erkrankungen des rheumatischen Formenkreises“.

Schlussfolgerung Die Anzahl der Fragen im 2. Staatsexamen aus dem Fach Chirurgie erscheint ausreichend, jedoch thematisch ungleichmäßig verteilt. Um eine inhaltlich homogenere Repräsentation relevanter chirurgischer Lernziele zu gewährleisten, ist eine bessere Abstimmung der Staatsprüfungen mit den existierenden Lernzielkatalogen durch das IMPP zu wünschen.

Postoperative outcome and quality of life after surgery for FAP-associated duodenal adenomatosis

INTRODUCTION

Prophylactic colon surgery has increased life expectancy of familial adenomatous polyposis patients. Extracolonic manifestations are life limiting, above all duodenal adenomas. Severe duodenal adenomatosis or cancer may necessitate pancreas-preserving total duodenectomy or partial pancreatico-duodenectomy, mostly after previous proctocolectomy and often after limited local resections of duodenal adenomas. Scarce information on long-term postoperative outcome and quality of life after surgery for duodenal adenomatosis is available. Aim of the present study was to analyze perioperative and long-term outcome after PD and PPTD for FAP-associated duodenal adenomatosis, including QoL and recurrence of adenomas in the neoduodenum after PPTD.

MATERIAL, METHODS AND PATIENTS

Thirty-eight patients, 27 after pancreas-preserving duodenectomy and 11 after partial pancreaticoduodenectomy, were included.

RESULTS

Pancreas-preserving total duodenectomy was associated with shorter operation time and less blood loss than partial pancreatico-duodenectomy. Clinically relevant pancreatic fistula occurred in 31.5%. In-hospital mortality was 5.3%. Long-term follow-up revealed recurrent pancreatitis after pancreas-preserving total duodenectomy in 22% of patients, two (7.4%) required re-operation. Recurrent adenomatosis was detected in 26% of patients. Quality of life was comparable to the German normal population after both surgical procedures. Patients with postoperative complications showed worse results than those without complications. Disease-specific 10-year survival rate with respect to duodenal adenomatosis was 100%.

CONCLUSION

Surgery for FAP-associated duodenal adenomatosis and cancer can be carried out with reasonable morbidity rates despite previous proctocolectomy. Long-term outcome, quality of life, and survival rates are favorable.

Double germline mutations in APC and BRCA2 in an individual with a pancreatic tumor

We report on three brothers affected by pancreatic tumors, all due to different causes, including mutations associated with two different cancer predisposition syndromes in the same individual. In the index patient a germline mutation both in the APC and BRCA2 gene was identified while one affected brother showed the BRCA2 mutation only and another brother is supposed to have developed pancreatic cancer due to multiple non-genetic risk factors. We outline the impact of a double germline mutation in two tumor predisposition genes in one individual and proven heterogeneity of multiple cases of pancreatic tumors in one family. With the growing implementation of next generation sequence based panel testing for multiple genes involved in tumor predisposition syndromes, relevant variants in two (or more) genes will be found more frequently. This family illustrates the importance of family studies, especially when using gene panel tests.

Competencies for first year residents - physicians' views from medical schools with different undergraduate curricula

BACKGROUND

Frameworks like the CanMEDS model depicting professional roles and specific professional activities provide guidelines for postgraduate education. When medical graduates start their residency, they should possess certain competencies related to communication, management and professionalism while other competencies will be refined during postgraduate training. Our study aimed to evaluate the relevance of different competencies for a first year resident required for entrustment decision from the perspective of physicians from medical faculties with different undergraduate medical curricula.

METHODS

Nine hundred fifty-two surgeons and internists from three medical schools with different undergraduate medical curricula were invited to rank 25 competencies according to their relevance for first year residents. The rankings were compared between universities, specialties, physicians' positions, and gender.

RESULTS

Two hundred two physicians participated, 76 from Hamburg University, 44 from Oldenburg University, and 82 from Technical University Munich. No significant differences were found regarding the top 10 competencies relevant for first year residents between the universities. 'Responsibility' was the competency with the highest rank overall. Internists ranked 'Structure, work planning and priorities' higher while surgeons ranked 'Verbal communication with colleagues and supervisors' higher. Consultants evaluated 'Active listening to patients' more important than department directors and residents. Female physicians ranked 'Verbal communication with colleagues and supervisors' and 'Structure, work planning and priorities' significantly higher while male physicians ranked 'Scientifically and empirically grounded method of working' significantly higher.

CONCLUSIONS

Physicians from universities with different undergraduate curricula principally agreed on the competencies relevant for first year residents. Some differences between physicians from different positions, specialties, and gender were found. These differences should be taken into account when planning competence-based postgraduate education training programs.

Neonatal Gardner Fibroma Leads to Detection of Familial Adenomatous Polyposis: Two Case Reports

Gardner fibromas (GFs) have only recently been described as poorly circumscribed tumor-like lesions, which are exceedingly rare in children. GFs are associated with APC gene mutations and therefore with familial adenomatous polyposis (FAP). So far there is only very limited literature on GF in the neonatal period. We present two children with GF diagnosed at birth and subsequent FAP with very different clinical courses. In one case, the disease led to extensive surgery of the thoracic wall and detection of FAP in the father with the need of immediate proctocolectomy. In the other patient (with a positive family history for FAP) the disease remained stable. Our cases indicate that the diagnosis of GF in the neonatal period requires the exclusion of FAP both in the child as well as the parents. Since the clinical behavior of GF cannot be predicted, continuous monitoring is mandatory. Depending on tumor site and growth, individual therapeutic options must be thoroughly considered. Surgical resection, if necessary, has to be inevitably total to prevent recurrence.

Improving teaching on the basis of student evaluation: integrative teaching consultation

Objective: Due to the development of medical education in the past decade the role of teachers has changed and requires higher didactic competence. Student evaluation of teaching alone does not lead to considerable improvement of teaching quality. We present the concept of "Integrative Teaching Consultation", which comprises both the teacher’s reflection and own objectives to improve their teaching as well as data from students ratings.

Methods: Teachers in collaboration with a teaching consultant reflect on their teaching ability and set themselves improvement goals. Then the consultant himself observes a teaching session and subsequently analyses the respective student evaluation in order to give meaningful feedback to the teacher.

Results: The combination of student feedback with professional consultation elements can initiate and maintain improvements in teaching.

Conclusion: Teaching consultation complements existing faculty development programs and increases the benefit of student evaluations.

Lehrenden- und studierenden-zentrierte Lehre messen

Zusammenfassung. Es besteht ein Bedarf an wissenschaftlich geprüften Beobachtungsinstrumenten zum Lehrverhalten an Hochschulen. Diese Arbeit stellt einen Beobachtungsbogen für Lehrveranstaltungen vor (BEO-LV), der lehrenden- und studierendenzentrierte Lehrhandlungen erfassen kann. Um bei den Lehrenden die Akzeptanz für die Datenerhebungen zu erhöhen, soll dieser gleichzeitig für didaktische Rückmeldungen genutzt werden. Zur psychometrischen Überprüfung des BEO-LV werden zwei Untersuchungen dargestellt: (1) Die Beurteilendenübereinstimmung und Interraterreliabilität in Lehrveranstaltungen erwiesen sich in einer Beobachtungsstudie als zufriedenstellend. (2) Die Überprüfung der Beurteilendenübereinstimmung und der internen Validität in einer Videostudie ergab zufriedenstellende Ergebnisse für Beobachtende mit fortgeschrittenen didaktischen Kenntnissen. Die Ergebnisse zeigen, dass der BEO-LV zur Messung des Lehrverhaltens eingesetzt werden kann. Voraussetzung für gute psychometrische Ergebnisse ist eine ausführliche Einarbeitung in die operationalen Definitionen der Beobachtungsitems.

Academic Performance of Students with the Highest and Mediocre School-leaving Grades: Does the Aptitude Test for Medical Studies (TMS) Balance Their Prognoses?

BACKGROUND

Admission to undergraduate medical training in Germany occurs by central and local pathways. Central admission includes two distinct groups: Students with top school-leaving grades (best-SLG group) and students with inferior school-leaving grades who are admitted with a delay of up to seven years (delayed admission group). Students with academic difficulties and early dropouts are present in both groups. Local admission at our university involves the German Test for Medical Studies (TMS) and allows the admission by merit of students with a wide range of school-leaving grades.

AIMS

To examine the justification of a TMS-based strategy to reduce the admission of potentially weak best school-leavers and enhance the admission of potentially able candidates with mediocre school-leaving grades.

METHOD

The prognostic contribution of the school-leaving (SL) GPA and the TMS to academic performance and to continuity in the pre-clinical part of the undergraduate medical program was examined in two study groups: best school leavers (SL grade 1.0, SL-GPA 823-900 points) and mediocre school leavers (SL grades 2.0-2.3, SL-GPA 689-660 points). The outcomes in both groups were compared in relation to their TMS results. The prospective study included four consecutive cohorts.

RESULTS

In each study group the TMS predicted the academic performance (β=0.442-0.446) and the continuity of studies (OR=0.890-0.853) better than the SL-GPA (β=0.238-0.047; OR=1.009-0.998). Attrition was most strongly associated with failing to take the TMS (OR=0.230-0.380). Mediocre school leavers with TMS scores ≥125 performed as well as the best school leavers. Mediocre school leavers with TMS scores between 110-124 performed on average less well but within the required standards. Best school leavers with mediocre TMS scores and 30% of the best school leavers who hadn't taken the TMS performed less well than most mediocre school leavers with high TMS scores.

DISCUSSION

The TMS appears to differentiate between potentially successful and less successful students in both GPA categories. Mediocre school leavers (SLG 2.0-2.3) with exceptionally high TMS results reach better pre-clinical examination results than best school leavers (SLG 1.0) with mediocre TMS results. Thus, the present data justify the use of the TMS to facilitate the participation of mediocre school leavers in the competition for admission slots.

"Heidelberg standard examination" and "Heidelberg standard procedures" - Development of faculty-wide standards for physical examination techniques and clinical procedures in undergraduate medical education

The competent physical examination of patients and the safe and professional implementation of clinical procedures constitute essential components of medical practice in nearly all areas of medicine. The central objective of the projects "Heidelberg standard examination" and "Heidelberg standard procedures", which were initiated by students, was to establish uniform interdisciplinary standards for physical examination and clinical procedures, and to distribute them in coordination with all clinical disciplines at the Heidelberg University Hospital. The presented project report illuminates the background of the initiative and its methodological implementation. Moreover, it describes the multimedia documentation in the form of pocketbooks and a multimedia internet-based platform, as well as the integration into the curriculum. The project presentation aims to provide orientation and action guidelines to facilitate similar processes in other faculties.

Prognosis of Ulcerative Colitis-Associated Colorectal Carcinoma Compared to Sporadic Colorectal Carcinoma: A Matched Pair Analysis

BACKGROUND

Ulcerative colitis (UC) patients have an increased risk of developing colorectal carcinoma (CRC). In contrast to clinical and pathogenetic differences, little is known about how prognosis compares between these patients and those with sporadic CRC. The aim of this study was to compare their characteristics and prognosis and identify independent risk factors for patients with UC-associated CRC.

METHODS

A total of 126 patients who underwent surgery in our department (1984-2010) for UC-associated (n = 63) or sporadic (n = 63) CRC were included in this analysis. Patients were matched according to sex, tumor location, and disease stage. Clinical parameters and overall, recurrence-free, and disease-specific survival were compared. In subgroup analyses, clinical parameters of UC patients were correlated with survival.

RESULTS

Median follow-up was 129 months in the UC group and 99 months in the sporadic CRC group. UC patients were significantly younger and had more multifocal, high-grade, and mucinous carcinomas. Five-year overall survival rate for UC-associated and sporadic CRC was similar (65.7 vs. 63.2%, p = 0.98). Recurrence-free survival for International Union Against Cancer (UICC) stage II disease was superior in the sporadic CRC group (p = 0.039). In a subgroup analysis of UC patients, a shorter duration of UC (p = 0.045) and male sex (p = 0.005) were associated with a worse prognosis.

CONCLUSIONS

Despite multiple clinical and histopathologic differences between UC-associated and sporadic CRC patients, overall survival and disease-specific survival are similar. In a subgroup analysis of UC patients with CRC, female sex was associated with a significantly better prognosis. This finding implies that estrogens may play a protective role in UC-associated CRC carcinogenesis.

Intestinal cytomegalovirus infection in patients hospitalized for exacerbation of inflammatory bowel disease: a 10-year tertiary referral center experience

OBJECTIVES

This 10-year retrospective cohort study aims to determine the prevalence and risk factors of cytomegalovirus (CMV) infection in inpatients with exacerbated inflammatory bowel disease (IBD).

METHODS

All patients admitted to the Department of Gastroenterology of the University Hospital Heidelberg for IBD exacerbation between January 2004 and June 2013 were enrolled. To identify the risk factors of CMV infection, infected individuals were compared with those with excluded infection.

RESULTS

Among 297 patients with exacerbated IBD, 21 had confirmed CMV infection and 79 had excluded CMV infection, whereas the remaining patients had not been sufficiently tested for CMV. Taking into account only sufficiently tested individuals, the prevalence of CMV infection was 22.7% in ulcerative colitis and 16.0% in Crohn's disease. The occurrence of CMV infection was associated with the following variables at admission: age of 30 years or more [odds ratio (OR) 14.29; P=0.004], disease duration less than 60 months (OR 7.69; P=0.011), a blood leukocyte count less than 11/nl (OR 4.49; P=0.041), and immunosuppressive therapy (OR 6.73; P=0.0129). CMV-positive patients remained in the hospital longer than noninfected patients (P=0.0009). In the CMV-positive cohort, a 66-year-old woman died of CMV pneumonia and sepsis, whereas there was no death in the CMV-negative cohort.

CONCLUSION

Immunuosuppressive therapy and age older than 30 years were identified as the main risk factors for the development of CMV infection in exacerbated IBD. Because of the risk of death, diagnostics of CMV infection should especially be initiated in older patients on immunosuppressive therapy.

Virtual reality training versus blended learning of laparoscopic cholecystectomy: a randomized controlled trial with laparoscopic novices

This study compared virtual reality (VR) training with low cost-blended learning (BL) in a structured training program.Training of laparoscopic skills outside the operating room is mandatory to reduce operative times and risks.Laparoscopy-naïve medical students were randomized in 2 groups stratified for sex. The BL group (n = 42) used E-learning for laparoscopic cholecystectomy (LC) and practiced basic skills with box trainers. The VR group (n = 42) trained basic skills and LC on the LAP Mentor II (Simbionix, Cleveland, OH). Each group trained 3 × 4 hours followed by a knowledge test concerning LC. Blinded raters assessed the operative performance of cadaveric porcine LC using the Objective Structured Assessment of Technical Skills (OSATS). The LC was discontinued when it was not completed within 80 min. Students evaluated their training modality with questionnaires.The VR group completed the LC significantly faster and more often within 80 min than BL (45% v 21%, P = .02). The BL group scored higher than the VR group in the knowledge test (13.3 ± 1.3 vs 11.0 ± 1.7, P < 0.001). Both groups showed equal operative performance of LC in the OSATS score (49.4 ± 10.5 vs 49.7 ± 12.0, P = 0.90). Students generally liked training and felt well prepared for assisting in laparoscopic surgery. The efficiency of the training was judged higher by the VR group than by the BL group.VR and BL can both be applied for training the basics of LC. Multimodality training programs should be developed that combine the advantages of both approaches.

Residual rectal mucosa after stapled vs. handsewn ileal J-pouch-anal anastomosis in patients with familial adenomatous polyposis coli (FAP)--a critical issue

INTRODUCTION

Restorative proctocolectomy has become the standard surgical procedure for familial adenomatous polyposis (FAP) patients. The use of stapler devices has initiated a controversial discussion concerning the ileal pouch-anal reconstruction. Some authors advocate a handsewn anastomosis after transanal mucosectomy. A double-stapled anastomosis leads to better functional results but seems to bear a higher risk of residual rectal mucosa with dysplasia and adenomas. The present study systematically analyses the rate of residual rectal mucosa after restorative proctocolectomy and handsewn vs. stapled anastomosis.

PATIENTS AND METHODS

One hundred FAP patients after restorative proctocolectomy undergoing regular follow-up at our outpatient clinic were included in the study. Proctoscopy with standardised biopsy sampling was performed.

RESULTS

Of the 100 patients, 50 had undergone a stapled and 50 a handsewn anastomosis. Median follow-up was 146.1 months (handsewn) vs. 44.8 months (stapled) (P < 0.0001). Eighty-seven patients received a proctoscopy with standardised biopsy sampling. Thirteen patients had been diagnosed with residual rectal mucosa before. Sixty-three patients (63 %) showed remaining rectal mucosa (42 (66.6 %) stapler, 21 (33.3 %) handsewn, P < 0.0001). Patients after stapled anastomosis had higher rates of circular rectal mucosa seams, while small mucosa islets predominated in the handsewn group. The rate of rectal adenomas was significantly higher in the stapler group (21 vs. 10, P = 0.02).

CONCLUSION

Rectal mucosa, especially wide mucosa seams, as well as rectal adenomas are found significantly more often after a stapled than after a handsewn anastomosis. As the follow-up interval in the stapler group was significantly shorter, the impact of these findings may still be underestimated.

Quality management of clinical-practical instruction for Practical Year medical students in Germany - proposal for a catalogue of criteria from the German Society of Medical Education

Objectives: Amended in 2013, the current version of the German Medical Licensure Regulation contains structural specifications that are also required of non-university institutions involved in Practical Year clinical training. The criteria are worded in relatively general terms. Furthermore, not all of the structural specifications can be readily applied to every subject area. In order to ensure commensurability in Practical Year instruction in Germany, not least in light of recently introduced Practical Year mobility, it is necessary to define consistent quality criteria for Practical Year training. The authors therefore propose a catalogue of criteria for the quality management process in Practical Year instruction facilities.

Methods: In January 2014, the board of directors of the German Society for Medical Education decided to establish a committee comprised of representatives from various German medical faculties. In a process similar to the Delphi methodology, the group developed criteria for structure, process and outcome quality in Practical Year training in Germany.

Results: The criteria developed for structure, process and outcome quality apply to Practical Year training in academic teaching hospitals and university medical centres. Furthermore, modalities for review are proposed.

Conclusions: The present catalogue of criteria is intended to contribute to the formation of a basis for the most consistent quality standards possible for Practical Year instruction in Germany.

[The competent surgeon. Bridging the gap between undergraduate final year and postgraduate surgery training]

Competency-based frameworks rely on relevant professional competency rather than formal regulations. The transitional phase between final year undergraduate and common trunk postgraduate medical training is characterized by an increase of professional responsibility whereby previously acquired knowledge, skills and abilities have to be merged and applied to patients. Undergraduate and postgraduate training programs should ensure a successive transfer of responsibility for medical practice to final year students and young residents depending on individual competence. The concept of entrustable professional activities (EPA) represents a curricular concept based on concrete medical tasks which may be assigned to the responsibility of the trainee.