Von Sick of ... zu Sick with ... zu Walk with ...: Die narrative Anerkennung individuellen Leidens und Lebens in der Medizin(ausbildung)

Every individual has its unique reasons for seeing a doctor. It follows that, in order to find the appropriate remedy for each case, doctors need to pay particular attention in their endeavour to understand the individual problem. Easy to say, but hard if not impossible to achieve: Not often having the time for long personal conversations, doctors are nevertheless expected to understand the positions and perspectives, the desires and priorities, the troubles and sufferings of others in order to provide them the exact help they need and / or want. This is a professional challenge that should be addressed appropriately in the course of medical education. Confronted with the otherness of the individual other, and therefore with the impossibility of a 100% accurate understanding of each other, doctors need the mindset to acknowledge individual problems as individual problems as well as the attitude to side with their patients against these problems nevertheless. In other words: doctors need to think in narrative dimensions. This paper wants to discuss the potentials, limits and risks of respective elements in medical education around two case studies developed at TUM Medical School

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

Use of Learning Media by Undergraduate Medical Students in Pharmacology: A Prospective Cohort Study

The ubiquity of the internet and computer-based technologies has an increasing impact on higher education and the way students access information for learning. Moreover, there is a paucity of information about the quantitative and qualitative use of learning media by the current student generation. In this study we systematically analyzed the use of digital and non-digital learning resources by undergraduate medical students. Daily online surveys and semi-structured interviews were conducted with a cohort of 338 third year medical students enrolled in a general pharmacology course. Our data demonstrate a predominant use of digital over non-digital learning resources (69 +/- 7% vs. 31 +/- 7%;p 300 pages) (10.6 +/- 3.3%),internet search (7.9 +/- 1.6%) and e-learning cases (7.6 +/- 3.0%). When comparing learning media use of teaching vs. pre-exam self-study periods, textbooks were used significantly less during self-study (-55%;p < 0.01), while exam questions (+334%;p < 0.01) and e-learning cases (+176%;p < 0.01) were utilized more. Taken together, our study revealed a high prevalence and acceptance of digital learning resources by undergraduate medical students, in particular mobile applications

How is modern bedside teaching structured? A video analysis of learning content, social and spatial structures

BACKGROUND: Bedside teaching (BST) is an essential and traditional clinical teaching format. It has been subject to various impediments and has transformed over time. Besides a decrease in bedside time, there has also been a didactic diversification. In order to use time at the bedside effectively and understand the current design of BST, we here offer an evidence-based insight into how BST is practiced. This may serve as a basis for a refinement of its didactic design. METHODS: In the current study, we investigate the interrelationships between learning content and the social as well as spatial structures of BST. To this end, we have empirically analysed almost 80 hours of video material from a total of 36 BST sessions with good interrater reliability. RESULTS: BST lasted on average 125 min, most of which was spent in plenary and less than a third of the time at the patient’s bedside. History taking was primarily practiced at the bedside while case presentations, clinical reasoning and theoretical knowledge were largely taught away from the patient. Clinical examination took place to a similar extent in the patient’s room and in the theory room. CONCLUSIONS: Even though the filmed BSTs are not purely “bedside”, the teaching format investigated here is a typical example of undergraduate medical education. In order to maximize the teaching time available, a suitable learning space should be provided in addition to the bedside. Moreover, the clinical examination should be revised in its general sequence prior to the BST, and conscious decisions should be made regarding the social structure so as to optimize the potential of small groups and plenary sessions

Educational intervention reduced family medicine residents’ intention to request diagnostic tests: results of a controlled trial

Objective Dealing with uncertainty is a core competence for physicians. To evaluate the impact of an educational intervention on family medicine residents’ (FMRs’) intention to request diagnostic tests and their attitudes toward uncertainty. Methods Nonrandomized controlled trial. Intervention group (IG) FMRs participated in interactive “dealing with uncertainty” seminars comprising statistical lessons and diagnostic reasoning. Control group (CG) FMRs participated in seminars without in-depth diagnostic lessons. FMRs completed the Dealing with Uncertainty Questionnaire (DUQ), comprising the Diagnostic Action and Diagnostic Reasoning scales. The Physicians’ Reaction to Uncertainty (PRU) questionnaire, comprising 4 scales (Anxiety Due to Uncertainty, Concern about Bad Outcomes, Reluctance to Disclose Uncertainty to Patients, and Reluctance to Disclose Mistakes to Physicians) was also completed. Follow-up was performed 3 months later. Differences were calculated with repeated-measures analysis of variance. Results In total, 107 FMRs of the IG and 102 FMRs of the CG participated at baseline and follow-up. The mean (SD) Diagnostic Action scale score decreased from 24.0 (4.8) to 22.9 (5.1) in the IG and increased in the CG from 23.7 (5.4) to 24.1 (5.4), showing significant group difference (P = 0.006). The Diagnostic Reasoning scale increased significantly (P = 0.025) without a significant group difference (P = 0.616), from 19.2 (2.6) to 19.7 (2.4) in the IG and from 18.1 (3.3) to 18.8 (3.2) in the CG. The PRU scale Anxiety Due to Uncertainty decreased significantly (P = 0.029) without a significant group difference (P = 0.116), from 20.5 (4.8) to 18.5 (5.5) in the IG and from 19.9 (5.5) to 19.0 (6.0) in the CG. Conclusion The structured seminar reduced self-rated diagnostic test requisition. The change in Anxiety Due to Uncertainty and Diagnostic Reasoning might be due to an unspecific accompanying effect of the extra-occupational seminars for residents

Specific feedback makes medical students better communicators

Background: Feedback is regarded a key element in teaching communication skills. However, specific aspects of feedback have not been systematically investigated in this context. Therefore, the aim of this study was to investigate the effectiveness of communication skills training (CST) integrating specific, structured and behavioral feedback. Methods: We condensed best practice recommendations for feedback in a CST for undergraduate medical students and compared the effect of specific, structured and behavior-orientated feedback (intervention group CST-behav) to general, experience-orientated feedback (CST- exp. as our control group) in a randomized controlled trial (RCT). We investigated changes on communication skills evaluated by independent raters, and evaluated by standardized patients (SP). To do that, every student was video-recorded in a pre and post assessment. Results: Sixty-six undergraduate medical students participated voluntarily in our study. Randomization did not result in equally skilled groups at baseline, so valid inter-group comparisons were not possible. Therefore, we analyzed the results of 34 students of our intervention group (CST-behav). Five out of seven domains in communication skills as evaluated by independent raters improved significantly, and there was a significant change in the global evaluation by SP. Conclusions: Although we were unable to make between-group comparisons, the results of the within group pre-post evaluation suggest that specific feedback helps improve communication skills

Heme oxygenase-1 and its metabolites affect pancreatic tumor growth in vivo

<p>Abstract</p> <p>Background</p> <p>Pancreatic cancer (PaCa) is a fatal human cancer due to its exceptional resistance to all current anticancer therapies. The cytoprotective enzyme heme oxygenase-1 (HO-1) is significantly overexpressed in PaCa and seems to play an important role in cancer resistance to anticancer treatment. The inhibition of HO-1 sensitized PaCa cells to chemo- and radiotherapy <it>in vitro</it>.</p> <p>Therefore, we investigated the effects of HO-1 and its metabolites biliverdin, carbon monoxide and iron on PaCa cells.</p> <p>PaCa cell lines with divergent HO-1 expression patterns were used in a murine orthotopic cancer model. HO-1 expression and activity was regulated by zinc (inhibition) and cobalt (induction) protoporphyrin. Furthermore, the influence of cellular HO-1 levels and its metabolites on effects of standard chemotherapy with gemcitabine was tested <it>in vivo </it>and <it>in vitro</it>.</p> <p>Results</p> <p>High HO-1 expression in PaCa cell lines was associated with increased chemoresistance <it>in vitro</it>. Chemoresistance to gemcitabine was increased during HO-1 induction in PaCa cells expressing low levels of HO-1. The inhibition of HO-1 activity in pancreatic tumors with high HO-1 boosted chemotherapeutic effects <it>in vivo </it>significantly. Furthermore, biliverdin and iron promoted PaCa resistance to chemotherapy. Consequently, specific iron chelation by desferrioxamine revealed profound anticancerous effects.</p> <p>Conclusion</p> <p>In summary, the inhibition of HO-1 and the chelation of iron in PaCa cells were associated with increased sensitivity and susceptibility of pancreatic tumors to chemotherapy <it>in vivo</it>. The metabolites biliverdin and iron seem to be involved in HO-1-mediated resistance to anticancer treatment. Therefore, HO-1 inhibition or direct interference with its metabolites may evolve new PaCa treatment strategies.</p

Investigation on the acquisition of scientific competences during medical studies and the medical doctoral thesis

Background: Not only the amount of research related contents in German medical studies are objects of criticism, but also the medical doctoral thesis. However, the question which research competences are truly acquired within medical school and the doctoral phase is empirically open, and is thus pursued in the following research study. Methods: We used data from the Bavarian Medical Graduate Panel Survey (MediBAP) (N=455), where respondents assessed their own research competences. To consolidate the data, we analysed qualitative interviews with doctoral medical graduates and students from the E-Prom study (N=14). Results: The quantitative analyses show that medical graduates evaluate the medical curriculum's research contents and their acquired competences as rather low. Doctoral graduates rate their competence of pursuing research independently higher than medical graduates who have not finished their doctorate. The qualitative analyses are in line with these results, as they point to the predominant development of competences during the doctoral phase. Despite this clearly positive trend, the majority of the respondents don't feel confident enough to undertake research independently also after attaining their doctoral degree. Conclusion: The results of this study emphasize the need for a more systematic and targeted mediation and review of research competences within the regular medical curriculum