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1.  Cost-effectiveness of peer role play and standardized patients in undergraduate communication training 
BMC Medical Education  2015;15:183.
The few studies directly comparing the methodological approach of peer role play (RP) and standardized patients (SP) for the delivery of communication skills all suggest that both methods are effective. In this study we calculated the costs of both methods (given comparable outcomes) and are the first to generate a differential cost-effectiveness analysis of both methods.
Medical students in their prefinal year were randomly assigned to one of two groups receiving communication training in Pediatrics either with RP (N = 34) or 19 individually trained SP (N = 35). In an OSCE with standardized patients using the Calgary-Cambridge Referenced Observation Guide both groups achieved comparable high scores (results published). In this study, corresponding costs were assessed as man-hours resulting from hours of work of SP and tutors. A cost-effectiveness analysis was performed.
Cost-effectiveness analysis revealed a major advantage for RP as compared to SP (112 vs. 172 man hours; cost effectiveness ratio .74 vs. .45) at comparable performance levels after training with both methods.
While both peer role play and training with standardized patients have their value in medical curricula, RP has a major advantage in terms of cost-effectiveness. This could be taken into account in future decisions.
PMCID: PMC4619415  PMID: 26498479
2.  Digital rectal examination skills: first training experiences, the motives and attitudes of standardized patients 
Physical clinical examination is a core clinical competence of medical doctors. In this regard, digital rectal examination (DRE) plays a central role in the detection of abnormalities of the anus and rectum. However, studies in undergraduate medical students as well as newly graduated doctors show that they are insufficiently prepared for performing DRE. Training units with Standardized Patients (SP) represent one method to deliver DRE skills. As yet, however, it is little known about SPs’ attitudes.
This is a qualitative study using a grounded theory approach. Interviews were conducted with 4 standardized patients about their experiences before, during and after structured SP training to deliver DRE competencies to medical students. The resulting data were subjected to thematic content analysis.
Results show that SPs do not have any predominant motives for DRE program participation. They participate in the SP training sessions with relatively little prejudice and do not anticipate feeling highly vulnerable within teaching sessions with undergraduate medical students.
The current study examined SPs’ motives, views, expectations and experiences regarding a DRE program during their first SP training experiences. The results enabled us to derive distinct action guidelines for the recruitment, informing and briefing of SPs who are willing to participate in a DRE program.
PMCID: PMC4322856  PMID: 25638247
Intimate physical examinations; Digital rectal examination; Standardized patients; Qualitative research
3.  Good exams made easy: The item management system for multiple examination formats 
BMC Medical Education  2012;12:63.
The development, implementation and evaluation of assessments require considerable resources and often cannot be carried out by a single faculty/institution. Therefore some medical faculties have founded cooperation projects which mainly focus on the exchange of multiple choice questions (MCQs).
Since these cooperation projects do not entirely support all relevant processes in terms of preparation, implementation and evaluation of assessment, in 2006 the Medical Assessment Alliance (MAA) was founded for mutual support. In addition to MCQs the MAA started to develop innovative assessment formats and facilitate content through a coordinated exchange of experiences. To support cooperation within this network, the web-based Item Management System (IMS) was developed which supports all processes of the assessment workflow as an all-in-one working platform.
At present, the Alliance has 28 partner faculties in Europe. More than 2.800 users in 750 working groups are collaborating. Currently 90.000 questions have been stored in the IMS. Since 2007, nearly 4.600 examinations have been successfully conducted.
This article describes in detail the unique features of the IMS and contrasts it with the item management systems of other associations.
PMCID: PMC3441576  PMID: 22857655
Assessment alliance; Quality control
4.  Evaluation of interprofessional education: lessons learned through the development and implementation of an interprofessional seminar on team communication for undergraduate health care students in Heidelberg – a project report 
Introduction: This project report describes the development, “piloting” and evaluation of an interprofessional seminar on team communication bringing together medical students and Interprofessional Health Care B.Sc. students at the Medical Faculty of Heidelberg University, Germany.
Project Description: A five-member interprofessional team collaborated together on this project. Kolb’s experiential learning concept formed the theoretical foundation for the seminar, which explored three interprofessional competency areas: team work, communication and values/ethics. Evaluation for the purposes of quality assurance and future curricula development was conducted using two quantitative measures:
descriptive analysis of a standardized course evaluation tool (EvaSys) ANOVA analysis of the German translation of the University of the West of England Interprofessional Questionnaire (UWE-IP-D).
Results: The key finding from the standardized course evaluation was that the interprofessional seminars were rated more positively [M=2.11 (1 most positive and 5 most negative), SD=1, n=27] than the monoprofessional seminars [M=2.55, SD=0.98, n=90]. The key finding from the UWE-IP-D survey, comparing pre and post scores of the interprofessional (IP) (n=40) and monoprofessional (MP) groups (n=34), was that significant positive changes in mean scores for both groups towards communication, teamwork and interprofessional learning occurred.
Conclusions: Lessons learnt included: a) recognising the benefit of being pragmatic when introducing interprofessional education initiatives, which enabled various logistical and attitudinal barriers to be overcome; b) quantitative evaluation of learning outcomes alone could not explain positive responses or potential influences of interprofessional aspects, which highlighted the need for a mixed methods approach, including qualitative methods, to enrich judgment formation on interprofessional educational outcomes.
PMCID: PMC4895838  PMID: 27280133
communication; competency-based education; interdisciplinary health team; interprofessional relations; professional education
5.  Electronic acquisition of OSCE performance using tablets 
Background: Objective Structured Clinical Examinations (OSCEs) often involve a considerable amount of resources in terms of materials and organization since the scores are often recorded on paper. Computer-assisted administration is an alternative with which the need for material resources can be reduced. In particular, the use of tablets seems sensible because these are easy to transport and flexible to use.
Aim: User acceptance concerning the use of tablets during OSCEs has not yet been extensively investigated. The aim of this study was to evaluate tablet-based OSCEs from the perspective of the user (examiner) and the student examinee.
Method: For two OSCEs in Internal Medicine at the University of Heidelberg, user acceptance was analyzed regarding tablet-based administration (satisfaction with functionality) and the subjective amount of effort as perceived by the examiners. Standardized questionnaires and semi-standardized interviews were conducted (complete survey of all participating examiners). In addition, for one OSCE, the subjective evaluation of this mode of assessment was gathered from a random sample of participating students in semi-standardized interviews.
Results: Overall, the examiners were very satisfied with using tablets during the assessment. The subjective amount of effort to use the tablet was found on average to be “hardly difficult”. The examiners identified the advantages of this mode of administration as being in particular the ease of use and low rate of error. During the interviews of the examinees, acceptance for the use of tablets during the assessment was also detected.
Discussion: Overall, it was found that the use of tablets during OSCEs was well accepted by both examiners and examinees. We expect that this mode of assessment also offers advantages regarding assessment documentation, use of resources, and rate of error in comparison with paper-based assessments; all of these aspects should be followed up on in further studies.
PMCID: PMC4606489  PMID: 26483854
Quality assurance; OSCE; computer-based assessments; tablets; iPad; IT solution
6.  Development of a competency-based formative progress test with student-generated MCQs: Results from a multi-centre pilot study 
Introduction: Progress tests provide students feedback on their level of proficiency over the course of their medical studies. Peer-assisted learning and competency-based education have become increasingly important in medical education. Although progress tests have been proven to be useful as a longitudinal feedback instrument, there are currently no progress tests that have been created in cooperation with students or that focus on competency in medical education.
In this study, we investigated the extent to which students can be included in the development of a progress test and demonstrated that aspects of knowledge related to competency can be represented on a competency-based progress test.
Methods: A two-dimensional blueprint for 144 multiple-choice questions (MCQs) covering groups of medical subjects and groups of competency areas was generated by three expert groups for developing the competency-based progress test. A total of 31 students from seven medical schools in Germany actively participated in this exercise. After completing an intensive and comprehensive training programme, the students generated and reviewed the test questions for the competency-based progress test using a separate platform of the ItemManagementSystem (IMS). This test was administered as a formative test to 469 students in a pilot study in November 2013 at eight medical schools in Germany. The scores were analysed for the overall test and differentiated according to the subject groups and competency areas.
Results: A pool of more than 200 MCQs was compiled by the students for pilot use, of which 118 student-generated MCQs were used in the progress test. University instructors supplemented this pool with 26 MCQs, which primarily addressed the area of scientific skills. The post-review showed that student-generated MCQs were of high quality with regard to test statistic criteria and content. Overall, the progress test displayed a very high reliability. When the academic years were compared, the progress test mapped out over the course of study not only by the overall test but also in terms of the subject groups and competency areas.
Outlook: Further development in cooperation with students will be continued. Focus will be on compiling additional questions and test formats that can represent competency at a higher skill level, such as key feature questions, situational judgement test questions and OSCE. In addition, the feedback formats will be successively expanded. The intention is also to offer the formative competency-based progress test online.
PMCID: PMC4606478  PMID: 26483859
progress test; competency-based; medical students; medical education; multiple-choice questions
7.  Introducing a curricular program culminating in a certificate for training peer tutors in medical education 
Aim: Student tutorials are now firmly anchored in medical education. However, to date there have only been isolated efforts to establish structured teacher training for peer tutors in medicine. To close this gap, a centralized tutor training program for students, culminating in an academic certificate, was implemented at Heidelberg University Medical School. The program also counts within the scope of the post-graduate Baden-Württemberg Certificate in Academic Teaching (Baden-Württemberg Zertifikat für Hochschuldidaktik).
Method: Based on a needs assessment, a modular program comprised of four modules and a total of 200 curricular units was developed in cooperation with the Department for Key Competencies and Higher Education at Heidelberg University and implemented during the 2010 summer semester. This program covers not only topic-specific training sessions, but also independent teaching and an integrated evaluation of the learning process that is communicated to the graduates in the form of structured feedback. In addition, to evaluate the overall concept, semi-structured interviews (N=18) were conducted with the program graduates.
Results: To date, 495 tutors have been trained in the basic module on teaching medicine, which is rated with a mean overall grade of 1.7 (SW: 0.6) and has served as Module I of the program since 2010. A total of 17% (N=83) of these tutors have gone on to enroll in the subsequent training modules of the program; 27 of them (m=12, f=15) have already successfully completed them. Based on qualitative analyses, it is evident that the training program certificate and its applicability toward the advanced teacher training for university instructors pose a major incentive for the graduates. For successful program realization, central coordination, extensive coordination within the medical school, and the evaluation of the attained skills have proven to be of particular importance.
Conclusion: The training program contributes sustainably to both quality assurance and professionalism, as well as to solving the issue of resources in medical education. The introduction and continued development of similar programs is desirable.
PMCID: PMC4027804  PMID: 24872854
Medical education; peer teaching; tutor training; curriculum; graduation certificate
8.  Genetic modulation of the serotonergic pathway: influence on weight reduction and weight maintenance 
Genes & Nutrition  2013;8(6):601-610.
The serotonergic pathway plays a major role in the development of obesity. Its activity can be modulated by the 5-HT transporter–linked polymorphic region in the SLC6A4 gene and the upstream variable number of tandem repeats polymorphism in the MAOA gene. We studied whether these genetic modulations have an influence on weight reduction and weight maintenance in a one-year weight reduction program (OPTIFAST®52). The polymorphisms were genotyped by PCR in a sample of 135 female and 67 male subjects with severe obesity (44 ± 13 years, 122.3 ± 22.2 kg, BMI: 41.7 ± 6.7 kg/m2). The program leads to a total weight loss of 19.9 ± 9.8 kg (16.9 ± 8.3 %) in women and 27.4 ± 13.6 kg (20.4 ± 9.9 %) in men. Anthropometric measurements and blood levels were determined at the start of the program (T0), after the weight reduction phase (T1) and after the subsequent weight maintenance phase at the end of the program (T2). Each polymorphism alone did not significantly influence weight loss or weight maintenance neither in men nor in women. However, women carrying both risk genotypes (SS and 3/3) displayed a lower total weight loss during the program (p = 0.05). This effect derived mainly from difficulties in the weight maintenance phase (p = 0.11), while the weight reduction phase was not affected (p = 0.61). No influence was found in men (p = 0.93). Modulation of the serotonergic pathway by carrying both risk alleles seems to influence success of weight loss programs in women with severe obesity due to problems in stabilizing body weight after weight reduction.
PMCID: PMC3824832  PMID: 23797338
Weight maintenance;  Weight regain;  Weight loss;  Obesity;  5-HTTPLR;  MAOA uVNTR;  SLC6A4
9.  Alterations in cardiac DNA methylation in human dilated cardiomyopathy 
EMBO Molecular Medicine  2013;5(3):413-429.
Dilated cardiomyopathies (DCM) show remarkable variability in their age of onset, phenotypic presentation, and clinical course. Hence, disease mechanisms must exist that modify the occurrence and progression of DCM, either by genetic or epigenetic factors that may interact with environmental stimuli. In the present study, we examined genome-wide cardiac DNA methylation in patients with idiopathic DCM and controls. We detected methylation differences in pathways related to heart disease, but also in genes with yet unknown function in DCM or heart failure, namely Lymphocyte antigen 75 (LY75), Tyrosine kinase-type cell surface receptor HER3 (ERBB3), Homeobox B13 (HOXB13) and Adenosine receptor A2A (ADORA2A). Mass-spectrometric analysis and bisulphite-sequencing enabled confirmation of the observed DNA methylation changes in independent cohorts. Aberrant DNA methylation in DCM patients was associated with significant changes in LY75 and ADORA2A mRNA expression, but not in ERBB3 and HOXB13. In vivo studies of orthologous ly75 and adora2a in zebrafish demonstrate a functional role of these genes in adaptive or maladaptive pathways in heart failure.
PMCID: PMC3598081  PMID: 23341106
biomarker; dilated cardiomyopathy; DNA methylation; epigenetics; heart failure
10.  Effectiveness of IV Cannulation Skills Laboratory Training and Its Transfer into Clinical Practice: A Randomized, Controlled Trial 
PLoS ONE  2012;7(3):e32831.
The effectiveness of skills laboratory training is widely recognized. Yet, the transfer of procedural skills acquired in skills laboratories into clinical practice has rarely been investigated. We conducted a prospective, randomised, double-blind, controlled trial to evaluate, if students having trained intravenous (IV) cannulation in a skills laboratory are rated as more professional regarding technical and communication skills compared to students who underwent bedside teaching when assessed objectively by independent video assessors and subjectively by patients.
Methodology and Principal Findings
84 volunteer first-year medical students were randomly assigned to one of two groups. Three drop-outs occurred. The intervention group (IG; n = 41) trained IV cannulation in a skills laboratory receiving instruction after Peyton's ‘Four-Step Approach’. The control group (CG; n = 40) received a bedside teaching session with volunteer students acting as patients. Afterwards, performance of IV cannulation of both groups in a clinical setting with students acting as patients was video-recorded. Two independent, blinded video assessors scored students' performance using binary checklists (BC) and the Integrated Procedural Protocol Instrument (IPPI). Patients assessed students' performance with the Communication Assessment Tool (CAT) and a modified IPPI. IG required significantly shorter time needed for the performance on a patient (IG: 595.4 SD(188.1)s; CG: 692.7 SD(247.8)s; 95%CI 23.5 s to 45.1 s; p = 0.049) and completed significantly more single steps of the procedure correctly (IG: 64% SD(14) for BC items; CG: 53% SD(18); 95%CI 10.25% to 11.75%; p = 0.004). IG also scored significantly better on IPPI ratings (median: IG: 3.1; CG: 3.6; p = 0.015;). Rated by patients, students' performance and patient-physician communication did not significantly differ between groups.
Transfer of IV cannulation-related skills acquired in a skills laboratory is superior to bedside teaching when rated by independent video raters by means of IPPI and BC. It enables students to perform IV cannulation more professionally on volunteer students acting as patients.
PMCID: PMC3299804  PMID: 22427895
11.  Physician and Patient Predictors of Evidence-Based Prescribing in Heart Failure: A Multilevel Study 
PLoS ONE  2012;7(2):e31082.
The management of patients with heart failure (HF) needs to account for changeable and complex individual clinical characteristics. The use of renin angiotensin system inhibitors (RAAS-I) to target doses is recommended by guidelines. But physicians seemingly do not sufficiently follow this recommendation, while little is known about the physician and patient predictors of adherence.
To examine the coherence of primary care (PC) physicians' knowledge and self-perceived competencies regarding RAAS-I with their respective prescribing behavior being related to patient-associated barriers. Cross-sectional follow-up study after a randomized medical educational intervention trial with a seven month observation period. PC physicians (n = 37) and patients with systolic HF (n = 168) from practices in Baden-Wuerttemberg. Measurements were knowledge (blueprint-based multiple choice test), self-perceived competencies (questionnaire on global confidence in the therapy and on frequency of use of RAAS-I), and patient variables (age, gender, NYHA functional status, blood pressure, potassium level, renal function). Prescribing was collected from the trials' documentation. The target variable consisted of ≥50% of recommended RAAS-I dosage being investigated by two-level logistic regression models.
Patients (69% male, mean age 68.8 years) showed symptomatic and objectified left ventricular (NYHA II vs. III/IV: 51% vs. 49% and mean LVEF 33.3%) and renal (GFR<50%: 22%) impairment. Mean percentage of RAAS-I target dose was 47%, 59% of patients receiving ≥50%. Determinants of improved prescribing of RAAS-I were patient age (OR 0.95, CI 0.92–0.99, p = 0.01), physician's global self-confidence at follow-up (OR 1.09, CI 1.02–1.05, p = 0.01) and NYHA class (II vs. III/IV) (OR 0.63, CI 0.38–1.05, p = 0.08).
A change in physician's confidence as a predictor of RAAS-I dose increase is a new finding that might reflect an intervention effect of improved physicians' intention and that might foster novel strategies to improve safe evidence-based prescribing. These should include targeting knowledge, attitudes and skills.
PMCID: PMC3283612  PMID: 22363553

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