Exploring the introduction of entrustment rating scales in an existing objective structured clinical examination

Background: The concept of EPAs is increasingly applied to assess trainees’ workplace performance by means of entrustment ratings. OSCEs assess performance in a simulated setting, and it is unclear whether entrustment ratings can be integrated into these exams. This study explores the introduction of an entrustment rating scale into an existing OSCE. Methods: A 6-point entrustment scale was added to the standard ratings in an OSCE administered prior to students’ final clerkship year in an undergraduate medical programme. Standard OSCE ratings assess clinical and communication skills. Assessors (n = 54) rated students’ performance (n = 227) on a diverse set of clinical tasks and evaluated the addition of entrustment scales to OSCEs. Descriptive and inferential statistics were calculated for analyses. Results: Student performance varied across the stations, as reflected in both the standard OSCE ratings and the added entrustment ratings. Students received generally high standard OSCE ratings, whereas entrustment ratings were more widely distributed. All students passed the OSCE, and only a small proportion of students did not reach the expected pass threshold of 60% on the standard ratings in the single stations. The proportion of students who did not reach the expected entrustment level in the respective stations was noticeably higher. Both the clinical and communication skill ratings were related to the entrustment rating in most OSCE stations. A majority of the assessors positively evaluated the addition of entrustment ratings into the OSCE. Discussion: The findings provide an empirical basis to broaden our understanding of the potential use of entrustment ratings in existing OSCEs. They provide directions for future, more specific studies. The ratings might be used for formative feedback on students’ readiness for workplace practice

What can we expect from medical graduates? Empirical survey on the performance of Core EPAs in the first days of residency

Background: Core Entrustable Professional Activities (EPAs) have been defined to specify the performance expectations for entering residents worldwide. The content of these EPAs was elaborated and validated primarily via medical expert consent approaches. The present study aims to collect empirical information on the actual task performance and supervision level of entering residents as a complementary methodological approach to enhance the content validity of a set of institutional EPAs. Methods: In the summers of 2017 and 2018, Charité medical graduates (n = 720) received a post-graduation survey by mail. The questionnaire covered the performance of Core EPAs, Core procedures and more advanced EPAs. Graduates were asked how frequently they had performed the respective EPAs since the start of residency and under what level of supervision. We expected the large majority of graduates (> 75%) to have performed the Core EPAs and procedures under at least indirect supervision. Results: In total, 215 graduates (30%) returned the questionnaire, and 131 (18%) surveys could be included in the data analysis. The majority of participants were female (63%) and worked in hospitals (50%) or in university medical centres (30%) across various medical disciplines. Among the Core EPAs, 10 out of 11 tasks had been performed by more than 75% of graduates since the start of residency, 9 under indirect supervision. Regarding the Core procedures, only 3 out of 13 procedures had been performed by the large majority of graduates under indirect supervision, and 10 procedures had not been carried out by at least one-third of participants. Among the 5 advanced EPAs, none of 5 had been performed by more than 75% of the participants since the start of residency, and 4 had been carried out by 50% under indirect supervision. Conclusions: The results of this study largely and complementarily confirm the validity of the defined Core EPAs representing realistic expectations for entry into residence at our institution. The low actual performance rate of Core procedures serves to stimulate an institutional discussion on their adjustment to better match the workplace reality

Medical students' ratings of the relevance and actual implementation of interprofessional education and preferences for teaching formats : comparison by gender and prior education

Objectives: Interprofessional education is becoming increasingly important for collaboration in patient care. In the national context, there are few empirical studies on the assessment of medical students as important stakeholders in their education. Method: Students (N=2,974) participated in a semester-wide online evaluation of the modular curriculum of medicine at the Charité Berlin. Socio-demographic data (including gender, completion of prior education/studies), assessments of the relevance and extent of interprofessional collaboration and preferences for interprofessional education in various teaching formats were collected. Results: In total, data from 1,019 students were included in the evaluation. The relevance of interprofessional collaboration was considered high by medical students. Female students rated the relevance higher than male students. The completion of pre-education (vocational training or study) had no additional influence. The actual implementation of interprofessional education was rated equally low by female and male students. Medical students rated patient-centred, interactive small group formats as particularly suitable for interprofessional education. There were no gender differences, but the effect was more pronounced among students with vocational training. Conclusion: The assessments of female and male students show a large difference between the perceived relevance and the actual implementation of interprofessional collaboration in the modular curriculum of medicine. This study provides an empirical basis for the actual implementation of interprofessional collaboration and students' views on suitable teaching formats for interprofessional education. Zielsetzung: Der interprofessionellen Ausbildung wird eine zunehmende Bedeutung für die Zusammenarbeit in der Patient*innenversorgung zugeschrieben. Im nationalen Kontext gibt es nur wenig empirische Untersuchungen zur Einschätzung von Medizinstudierenden als wichtige Stakeholder für ihre Ausbildung. Methodik: In einer semesterübergreifenden Studiengangsevaluation des Modellstudiengangs Medizin der Charité wurden Studierende (N=2.974) online-basiert befragt. Es wurden soziodemografischen Daten (u. a. Geschlecht, Abschluss einer Ausbildung/eines Studiums) und Einschätzungen zu Relevanz und Ausmaß der Vermittlung interprofessioneller Zusammenarbeit sowie der Wunsch nach interprofessioneller Lehre in verschiedenen Lehrformaten erhoben.Ergebnisse: Insgesamt gingen Daten von 1.019 Studierenden in die Auswertung ein. Die Relevanz interprofessioneller Zusammenarbeit wurde von den Medizinstudierenden als hoch eingeschätzt. Studentinnen bewerteten die Relevanz höher als Studenten, eine abgeschlossene Vorausbildung (Berufsausbildung oder Studium) hatte keinen zusätzlichen Einfluss. Der Vermittlungsumfang interprofessioneller Ausbildung wurde von weiblichen und männlichen Studierenden gleich niedrig einschätzt. Medizinstudierende schätzen patient*innenzentrierte, interaktive Kleingruppenformate als besonders geeignet für interprofessionelle Lehre ein. Hier zeigten sich keine Geschlechterunterschiede, der Effekt war ausgeprägter bei Studierenden mit beruflicher Vorbildung. Schlussfolgerung: Die Einschätzung der weiblichen und männlichen Studierenden zeigt eine große Differenz zwischen eingeschätzter Relevanz und tatsächlicher Vermittlung von interprofessioneller Zusammenarbeit im Medizinstudium auf. Diese Studie liefert eine empirische Basis für eine Einschätzung des Ausmaßes und der von den Studierenden gewünschten Umsetzung in verschiedenen Lehrformaten

Medical students’ preparedness for professional activities in early clerkships

Background Sufficient preparedness is important for transitions to workplace participation and learning in clinical settings. This study aims to analyse medical students’ preparedness for early clerkships using a three-dimensional, socio-cognitive, theory-based model of preparedness anchored in specific professional activities and their supervision level. Methods Medical students from a competency-based undergraduate curriculum were surveyed about preparedness for 21 professional activities and level of perceived supervision during their early clerkships via an online questionnaire. Preparedness was operationalized by the three dimensions of confidence to carry out clerkship activities, being prepared through university teaching and coping with failure by seeking support. Factors influencing preparedness and perceived stress as outcomes were analysed through step-wise regression. Results Professional activities carried out by the students (n = 147; 19.0%) and their supervision levels varied. While most students reported high confidence to perform the tasks, the activity-specific analysis revealed important gaps in preparation through university teaching. Students regularly searched for support in case of difficulty. One quarter of the variance of each preparedness dimension was explained by self-efficacy, supervision quality, amount of prior clerkship experience and nature of professional activities. Preparedness contributed to predicting perceived stress. Conclusions The applied three-dimensional concept of preparedness and the task-specific approach provided a detailed and meaningful view on medical students’ workplace participation and experiences in early clerkships

Health care research based on an analysis of health insurance data

Depressive Syndrome zählen zur zweitgrößten Gruppe psychischer Störungen jenseits des 60. Lebensjahres. Sie werden im höheren Lebensalter nicht nur weniger diagnostiziert, sondern die Betroffenen erhalten bei korrekter Diagnosestellung zumeist eine Fehl- oder Unterversorgung. Bislang liegen im deutschsprachigen Raum keine Leitlinien zur Therapie der Altersdepression vor. Angesichts des demographischen Wandels wird die Prävalenz depressiver Syndrome deutlich zunehmen und ihre adäquate Therapie an Bedeutung gewinnen. In der Dissertation werden Befunde zur Versorgungsepidemiologie depressiver Syndrome im Alter auf der Basis von Krankenkassenroutinedaten gewonnen. Erstens wird das depressionsassoziierte Versorgungsgeschehen beleuchtet und eine gesicherte Grundlage für eine evidenzbasierte Qualitätssteigerung geschaffen. Zweitens wird eine vergleichende Analyse der Leistungsinanspruchnahme durch depressive Ältere sowie durch die nichtdepressive Versichertenmehrheit durchgeführt. Auf der Basis von Sekundärdaten einer deutschen Krankenversicherung wird die gesundheitliche Versorgung über 60-Jähriger mit depressiven Syndromen unterschiedlicher Schweregrade analysiert. Über einen Zeitraum von 3 Jahren wurden aus einer Kohorte von 73.193 Versicherten drei Untersuchungsgruppen (Versicherte mit leichter depressiver Symptomatik (N = 8.303); Versicherte mit manifestem depressiven Syndrom (N = 4.021); Versicherte mit schwerem depressiven Syndrom (N = 340)) identifiziert. Eine alters- und geschlechtspezifische Analyse der psychopharmakologischen Versorgung wurde in Hinblick auf ihre Leitlinienkonformität versus ihre potentielle Unangemessenheit durchgeführt. Die Schwerpunkte lagen hierbei auf der Versorgung mit potentiell unangemessenen Trizyklika und SSRI sowie mit leitlinienkonformen Anderen Antidepressiva und SSRI. Die Untersuchung der Leistungsinanspruchnahme durch depressive Ältere sowie durch die nichtdepressive Versichertenmehrheit fokussierte insbesondere auf die Leistungsbereiche Krankenhaus und Arzneimittel. Die drei Untersuchungsgruppen der leicht bis schwer depressiv Erkrankten bestehen zu mehr als zwei Dritteln aus 60 bis 69-Jährigen. Lediglich jeweils jeder Zehnte ist hochaltrig. Frauen stellen mehr als zwei Drittel dieser Untersuchungsgruppen. Rund 75% der Versicherten jenseits des 60. Lebensjahres mit depressiven Syndromen unterschiedlicher Schweregrade erhalten ein Trizyklikum und sind somit antidepressiv fehlversorgt. Amitriptylin- und Doxepinverordnungen dominieren die tri- und tetrazyklische Verordnungspraxis für alle drei Gruppen depressiv Erkrankter. Frauen erhalten deutlich häufiger die potentiell unangemessenen Trizyklika Amitriptylin und Doxepin. Immerhin fast jeder zweite aller hier untersuchten über 60-jährigen Depressiven wird leitlinienkonform mit Citalopram therapiert. Auch die Mirtazapin- Verordnungspraxis differiert deutlich für den ambulanten und stationären Bereich. Über 60-Jährige mit depressiven Zustandsbildern generieren innerhalb des Untersuchungszeitraums gegenüber der nichtdepressiven Versichertenmehrheit doppelt so hohe Gesamtversorgungskosten. Insbesondere das mittlere Alter ist mit ganz besonders hohen Gesamtversorgungskosten verbunden, wobei Männer insgesamt deutlich höhere Gesamtversorgungskosten als die Frauen erzeugen. Die gewonnenen Befunde können dazu dienen, Informationsmaterial über die leitlinienkonforme bzw. potentiell unangemessene Psychopharmakotherapie der Altersdepression für Haus- und Fachärzte zu entwickeln.Late life depression is common and associated with inadequate recognition and treatment. As of today no evidence based guidelines for detection and treatment of depressive syndromes in the elderly were published in Germany. Considering the demographic change there are strong indications that the prevalence of late life depression will increase. Therefore, an adequate treatment will be a great challenge for society in the future. Evidence on health care provision of late life depression is based upon health insurance data. At first provision of healthcare associated with depressive disorders in the elderly is analyzed. Second a comparative analysis of health care utilization by depressed to non- depressed elderly insured is being accomplished. Health care provision for elderly (60+ years) with depressive disorders of different levels of severity is being analyzed, based on health insurance data of a major German health insurance. Three groups (with mild depressiv symptoms (N= 8.303); manifest depressive syndromes (N=4.021); with severe depressive syndromes (N= 340) were identified among a cohort of 73.173 insurants over a period of three years. Psychotropic medications were analyzed by age and gender to detect, wether they were consistent with evidenced based treatment guidelines or whether they were potentially inappropriate. The focus is on potentially inappropriate treatment with tricyclica and several SSRIs and guideline compliant treatment with other antidepressants and SSRI. Utiliziation of services among insured with and without depressive syndromes focuses on inpatient services and medication. Two third of the insured were 60 to 69 years of age, one out of ten is of old aged, and two thirds are female. 75 % of all insurants over and above the age of sixty are treated with tricylcica and therefore receive incorrect medication. Obviously, this inadequate medication with amitriptyline and doxepin is still the preferential treatment for late life depression. Women are treated with potentially inadequate medications like amitriptyline and doxepine more often than men. Almost every second depressed participant receive citalopram being the treatment recommended by the guidelines. In this study, old people with depressive disorders generate twice as much total health care costs as elderly without any depressive syndrome. Middle aged people cause particularly high healthcare costs. In general men clearly cause higher total health care costs then women. The results of this study could be used to develop information material for family practicioners about guideline conforming treatment and potentially inappropriate psychotropic medication of late life depression

Doctors on the move: a qualitative study on the driving factors in a group of Egyptian physicians migrating to Germany

Abstract Background Migration of physicians has become a global phenomenon with significant implications for the healthcare delivery systems worldwide. The motivations and factors driving physician’s migration are complex and continuously evolving. Purpose of this study is to explore the driving forces in a group of Egyptian physicians and final-years medical students preparing to migrate to Germany. Methods A qualitative study was conducted based on social constructivism epistemology. In five focus group discussions, there participated a total 12 residents and 6 final-year medical students from 7 different training and workplace locations in Egypt. The participants provided information about their motivation and planning for migration. We applied a coding framework based on the concept of push/pull factors and barriers/facilitators for migration, and used Atlas.ti software for analysis. Results The thematic analysis indicated that the migration within the study’s participants results from a specific weighting of push and pull factors. Push factors are considered to be more important than pull factors. Factors related to professional development play a leading role. The route of migration towards Germany is mainly determined by the low hurdle registration and licensing requirements in this destination country compared to other countries. In some cases, Germany is regarded as a “transit country”, a step on the road to other European countries. The intent, planning and preparation of migration is assisted considerably by the local formation of a community and culture of migration with multiple ways for information exchange, identity building and social support through face-to-face and online channels. Conclusions This study specifies – in a group of Egyptian physicians and final-year medical students – the perceived push and pull factors which influenced their intent to migrate to Germany. In addition to the general wealth gap, their particular route of migration is mainly determined by the requirements in licensing and registration procedures for foreign physicians in the potential destination country. The planning and preparation of a move is substantially facilitated by their joining a social network and a community of migrating physicians

Introducing an assessment tool based on a full set of end-of-training EPAs to capture the workplace performance of final-year medical students

BackgroundWhile literature on the theoretical value of entrustable professional activities (EPAs) for assessment is rapidly expanding, little experience exists on its application. The aims of this study are to develop and explore the utility of an EPA-based assessment tool for capturing the workplace performance of final-year medical students based on a full set of end-of-training EPAs.MethodsThe tool was developed in a systematic iterative process. Twelve 12 end-of-undergraduate medical training EPAs were nested into 72 smaller EPAs and cross-mapped onto a 6-point supervision level scale, both adjusted to the context of final-year clerkships. One version was created for students' self-assessment of their ability to carry out tasks and their history of carrying out tasks, and another version was created for supervisors' assessment of students' ability to carry out tasks. The tool was administered to final-year clerkship students and their clinical supervisors to explore its utility as an assessment approach. The results were analysed using descriptive and interferential statistics.ResultsWe enrolled a total of 60 final-year medical students. For 33 students, ratings were provided from one supervisor and for 27 students from two supervisors. With regard to the reliability and validity of the tool, students' and supervisors' ratings showed an overall good internal consistency as well as variability between and within the EPAs. Over the full EPA range, students rated their ability to perform a task slightly higher than their task performance history and slightly lower than the supervisors' ratings. Students' self-ratings of their ability to perform a task correlated with their history in performing the task. Supervisors' ratings correlated among supervisors and not with students' ratings. Concerning educational outcomes, supervisors' average rating of students' ability to perform the EPAs without direct supervision was 64%, and key findings being double-checked.ConclusionsThis study introduces a tool that is adjusted to the final-year clerkship context and can assess the workplace performance of trainees based on a full set of end-of-training EPAs. Its utility characteristics suggest that the tool may be employed as a formative and outcome-aligned approach to the assessment of final-year students before entering into residency.</p

How to define core entrustable professional activities for entry into residency?

Abstract Background Institutions considering to employ core Entrustable Professional Activities (EPAs) for entry into postgraduate training as outcomes for their undergraduate medical programs can partly build on published examples, but also have to undergo their own content validation process to take their specific context into consideration. This process involves several challenges and is not well-described in the literature. Here, we report in detail on a systematic, literature-based approach we recently utilised at our institution to define core EPAs for entry into residency. Main body Central to the process was a modified Delphi consent procedure. It involved a multistep interaction between a writing team and a multidisciplinary panel of experienced physicians. Panel members provided both quantitative ratings and qualitative feedback on the EPA categories title, specification/limitations, conditions and implications of entrustment decision, knowledge, skills, and attitude. Consent was achieved when a Content Validity Index (CVI) of ≥80% was reached. The writing team adjusted the EPA category descriptions on the basis of panel members´ ratings and comments, and specified the EPA categories’ link to competencies and assessment sources. This process produced a description and definition of a full set of core EPAs for entry into residency adapted to our context. Conclusions This process description for locally adapted core EPAs for entry into residency may support and guide other medical schools in the development and implementation of EPAs into their programs

Moving a mountain: Practical insights into mastering a major curriculum reform at a large European medical university

Aim: Undergraduate medical education is currently in a fundamental transition towards competency-based programs around the globe. A major curriculum reform implies a dual challenge: the change of the curriculum and the delivering organization. Both are closely interwoven. In this article, we provide practical insights into our approach of managing such a fundamental reform of the large undergraduate medical program at the Charité – Universitätsmedizin Berlin. Methods: Members of the project management team summarized the key features of the process with reference to the literature. Results: Starting point was a traditional, discipline-based curriculum that was reformed into a fully integrated, competency- based program. This change process went through three phases: initiation, curriculum development and implementation, and sustainability. We describe from a change management perspective, their main characteristics, and the approaches that were employed to manage them successfully. Conclusions: Our report is intended to provide practical insights and guidance for those institutions which are yet considering or have already started to undergo a major reform of their undergraduate programs towards competency medical education

The modular curriculum of medicine at the Charité Berlin – a project report on the basis of a term-overarching student evaluation

Aim: The introduction of a reform clause into the German licensing laws for medical doctors has enabled German faculties to pilot alternative designs for medical degree programmes. The aim of this project report is to outline the curricular features of the modular curriculum of medicine (MCM) at the Charité and to assess the results of its implementation based on a student evaluation across semesters. Project outline: The MCM was planned and implemented in a competency- and outcome-based manner from 2010-2016 in a faculty-wide process. The curriculum is characterised by a modular structure, longitudinal teaching formats and the integration of basic and clinical science. In the winter semester 2017, evaluations by students in semesters 1-10 were carried out. The results were analysed descriptively, and the coverage of overarching learning outcomes was compared to the results of a survey carried out amongst students on the traditional regular curriculum of medicine track in 2016. Results: A total of 1,047 students participated in the across-semester evaluation (return rate 35%). A high percentage of the respondents positively rated the achieved curricular integration and longitudinal teaching formats. The majority of the respondents agreed with the relevance of the overarching learning outcomes. Students’ evaluations of the coverage of learning outcomes showed a differentiated picture for the MCM. Compared to the regular curriculum track, the coverage in the MCM programme showed substantial improvements in all aspects. Students found themselves to be better prepared for the M2 state examination and the practical year. The students’ overall satisfaction with their decisions to study in the MCM was high. Conclusions: The results of the student evaluation show that a significant improvement in medical education has been achieved at the Charité with the new integrated, outcome-oriented design and the implementation of the MCM. At the same time, ongoing weaknesses have been revealed that serve as a basis for the continued development of the curriculum. This report aims to contribute to the discussion of the future of undergraduate medical education in Germany