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Background: Since its academic inception in the 1960s, Germany's general practice has seen numerous dissertations, many of which are housed in the 'Archive of German language General Practice' (ADAM)., Aim: This study aims to provide the first comprehensive overview of dissertation topics from the discipline of general- and family medicine in Germany, establishing a foundation for advancing research., Method: We employed a systematic review approach, examining 801 dissertations from both ADAM and online sources. Each topic was identified, categorized, and finalized through consensus by two independent reviewers., Results: Our analysis encompassed 486 dissertations from ADAM, 176 from the German national library, and 139 from university libraries. A total of 167 unique research topics were identified. The predominant themes included medical education ( n  = 49), medication orders ( n  = 39), frequent consultation issues ( n  = 33), complementary medicine ( n  = 32), and screening measures ( n  = 29). The use of qualitative methods was constantly rising, from no qualitative methods used from 1965-1974, up to 22% of dissertations in recent years., Conclusion: The diversity of 167 research topics underscores the vastness and complexity of general practice in Germany. This structured overview is pivotal for facilitating focused and interconnected research endeavors in the field.

Background: Digitalization in the German health care system is progressing slowly, even though it offers opportunities for improvement of care. In nursing homes, most of the staff's work is paper based. Following the pandemic, there has been a decrease in the use of telemedicine applications. To ensure long-term implementation, the views of users, in this case nurses, are of interest., Objective: This cross-sectional study was conducted to describe which digital applications are already being used at inpatient care facilities, the attitude of nurses toward telemedicine, and for which areas the use of telemedicine in the facilities is considered appropriate by the participants., Methods: All inpatient care facility staff in Schleswig-Holstein were invited to participate in the survey from August 1 to October 31, 2022. The questionnaire consists of 17 determinants that ask about the attitude, use, and possible applications of telemedicine. In addition to a descriptive analysis, the influence of the general attitude toward telemedicine on various determinants was examined using the Fisher exact test for nominal variables and Spearman correlation coefficient for metric variables., Results: A total of 425 caregivers participated in the survey. Of these respondents, 10.7% (n=41) currently used video consultations, and 76.1% (n=321) of the respondents were in favor of video consultations being practiced in training. Furthermore, 74.8% (n=312) of the respondents would attend a training on telephone medical consultation. Respondents indicated that video consultations have a small added value compared to asynchronous telemedicine (eg, sending photos). However, video consultations were perceived as somewhat less time-consuming than other communication channels. Video consultations are perceived as most useful for clarifying urgent problems. The respondents estimated that one in five paramedic calls at their facilities could be reduced through telemedicine approaches. It was important to the participants that telemedicine is as simple as possible and that there is a high level of data security., Conclusions: Although many caregivers have a positive attitude toward telemedicine and perceive its advantages, communication channels such as video consultation are still used infrequently in care facilities. To promote the use of telemedicine applications, it is important to emphasize their benefits. The presumed saving of paramedic calls thus represents a benefit, and it is crucial to train caregivers in the use of telemedicine to avoid uncertainties in dealing with the newer technologies. It is important to give them enough time and repetitions of the training., (© Pia Traulsen, Lisa Kitschke, Jost Steinhäuser. Originally published in JMIR Aging (https://aging.jmir.org).)

Background: Foot orthoses (FOs) are prescribed by general practitioners (GPs) and orthopedic surgeons for various complaints. As there are very limited medical guidelines and checklists, the prescription of FOs is often inconsistent. Therefore, our study to evaluate the general prescription behavior and indication experiences with FOs from the perspective of GPs and orthopedists., Methods: A survey was carried out using a questionnaire from October to December 2021. GPs and orthopedic surgeons in northern Germany were included. The focus of the survey was to examine which foot problems would lead GPs and orthopedic surgeons to prescribe FOs and to evaluate what factors these physicians included in their diagnostic analysis. Apart from descriptive analyses, a stepwise linear regression analysis was performed to explore potential associations of the primary outcome variable 'specific effect on the prescription of FOs', which was introduced to shed light upon the estimated added value of the prescription of FOs., Results: Out of the 790 questionnaires distributed, 184 questionnaires were returned by GPs (n = 95) and orthopedic surgeons (n = 74) (response rate 23 %). FOs were most frequently prescribed for talipes valgus (96 %) and heel spur (54 %). Diagnostic analysis was mainly carried out clinically. Custom-made FOs (82 %) were prescribed more frequently than prefabricated FOs (6 %). Regular interaction within the prescription process was most commonly with orthopedic technicians (61 %). The estimation of the specific effect on FO prescription was assessed by a mean of 66 % of the participants, 82 % recommended self-exercises as an additional therapy., Conclusions: FOs are a specific and well-established aid prescribed by many GPs and orthopedic surgeons for a variety of foot complaints. Despite being one of the most frequently prescribed orthopedic devices, the utilization of FOs is predominantly explorative due to a growing but nevertheless still deficient body of well-researched evidence. There is a clear need for a uniform approach to the indication and prescription of FOs among physicians., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Background: There is a discussion among general practitioners and psychiatrists regarding over-diagnosing versus under-reporting of psychiatric diagnoses. A deeper understanding of this topic is relevant for providing reasonable health care and for planning future studies. A crucial factor to understanding this discussion is the difference in the prevalence of a disease in each sector. One way to attain knowledge about such prevalences is the analysis of routine care data of the sector in question. However, diagnosis-related data might be modified by several additional influencing factors., Aims: This study aims to explore what kind of motives and modifying factors play a role for or against giving psychiatric diagnoses in psychiatric and general medical settings., Methods: Twenty-six semi-structured interviews were conducted with German physicians in the fields of general medicine and psychiatry. Interviews were analysed using content analysis., Results: The analysis revealed three major motivational categories for finding a diagnosis: (1) "objective matters" such as "categorisation for research"; (2) "functional and performance-related factors" such as "requirement for medication", "billing aspects" that go with certain diagnoses or "access to adequate care" and (3) "Individual factors" such as the "personality of a physician". Similarly, factors emerged that lead to not making psychiatric diagnoses like "fear of stigmatization among patients" or "detrimental insurance status with psychiatric diagnosis". Additionally participants mentioned other reasons for "not diagnosing a psychiatric diagnosis", such as "coding of other clinical pictures"., Conclusion: The diagnostic process is a complex phenomenon that goes far beyond the identification of medical findings. This insight should be considered when processing and interpreting secondary data for designing health care systems or designing a study., (© 2024. The Author(s).)

Background: During the restrictions on human contact in the COVID-19 pandemic, nursing homes made a great effort to allow relatives, doctors and other persons involved in the care to communicate with residents. For this purpose, the HLTeleheim project offered a practical telemedical support option. This offer was accepted and implemented in a heterogeneous way. The aim of this study was to detect factors that have an influence on the implementation of telemedical applications in long-term care facilities., Methods: As part of a qualitative evaluation approach, guideline-centered interviews (n=17) were conducted with nurses, doctors and administrative staff from the facilities invited to participate in the project. These interviews were then transcribed and anonymized. The evaluation was carried out according to Mayring's qualitative analysis. The code system was created deductively and inductively. Two independently working persons analyzed the interviews., Results: While a high demand for applications of telemedicine in nursing care was seen in the run-up to the project, considerable barriers emerged during the implementation, and acceptance among the interviewees was mixed. The nurses regarded the regular use of telemedicine as being rather unimportant for their work. Technical and organizational problems were seen as barriers by the interviewees, which partly limited the use of telemedicine applications. Compatibility among the applications used was seen as a prerequisite of effective use. Unstable internet connection was an important limiting determinant. It turned out that consultations were used for communication within the team., Discussion: Although the advantages of video consultations are being recognized among nursing staff, they are still little used. In order to promote the use of telemedicine applications, it is important to repeatedly point out their individual advantages in internal and external communication. Another approach to further implementation, in addition to financial and technical aspects, is to directly address the nursing profession in the software products to be used., Conclusion: The implementation of telemedicine applications in long-term care facilities faces structural barriers, such as insufficient internet coverage and a lack of billing options, as well as personal hurdles, such as a low affinity for technology and a lack of knowledge on the subject of telemedicine., (Copyright © 2024. Published by Elsevier GmbH.)

Background: Orthopaedic insoles (OI) are used to treat a variety of foot problems., Objectives: The aim of this cross-sectional study was to investigate the perceptions of the treatment with OI among the manufacturers of the OIs, the orthopaedic technicians (OT)., Methods: OT from the federal states of Schleswig-Holstein and Lower Saxony in Germany were invited to take part in a survey. The questions included, among others, the number of prescriptions for the production of an OI per month and the materials used. Descriptive statistics, subgroup analyses and a linear regression analysis were performed., Results: Of the 312 questionnaires distributed, 159 were completed (response rate 51%). Most of the respondents were male (80%). The average age of the participants was 50. On average, OT produced 290 OI per month, with plastic being the most commonly used material (73%). OT with less than 20 years of professional experience are more likely to follow the doctor's instructions when producing OI than OT with more than 20 years of professional experience. The latter are more likely to base their decisions regarding the manufacture and issuing of OI on their own experience., Conclusions: The production and issuing process of OI differs among OT. The different professional perspectives of the OT could play a role here, as does the lack of a standardized procedure. The factors listed in this study represent potential starting points for future research projects that could contribute to the development of evidence-based standards., (© 2024. The Author(s).)

Background: Digital transformation offers new opportunities to improve the exchange of information between different health care providers, including inpatient, outpatient and care facilities. As information is especially at risk of being lost when a patient is discharged from a hospital, digital transformation offers great opportunities to improve intersectoral discharge management. However, most strategies for improvement have focused on structures within the hospital., Objective: This study aims to evaluate the implementation of a digitalized discharge management system, the project "Optimizing instersectoral discharge management" (SEKMA, derived from the German Sektorübergreifende Optimierung des Entlassmanagements), and its impact on the readmission rate., Methods: A mixed methods design was used to evaluate the implementation of a digitalized discharge management system and its impact on the readmission rate. After the implementation, the congruence between the planned (logic model) and the actual intervention was evaluated using a fidelity analysis. Finally, bivariate and multivariate analyses were used to evaluate the effectiveness of the implementation on the readmission rate. For this purpose, a difference-in-difference approach was adopted based on routine data of hospital admissions between April 2019 and August 2019 and between April 2022 and August 2022. The department of vascular surgery served as the intervention group, in which the optimized discharge management was implemented in April 2022. The departments of internal medicine and cardiology formed the control group., Results: Overall, 26 interviews were conducted, and we explored 21 determinants, which can be categorized into 3 groups: "optimization potential," "barriers," and "enablers." On the basis of these results, 19 strategies were developed to address the determinants, including a lack of networking among health care providers, digital information transmission, and user-unfriendliness. On the basis of these strategies, which were prioritized by 11 hospital physicians, a logic model was formulated. Of the 19 strategies, 7 (37%; eg, electronic discharge letter, providing mobile devices to the hospital's social service, and generating individual medication plans in the format of the national medication plan) have been implemented in SEKMA. A survey on the fidelity of the application of the implemented strategies showed that 3 of these strategies were not yet widely applied. No significant effect of SEKMA on readmissions was observed in the routine data of 14,854 hospital admissions (P=.20)., Conclusions: This study demonstrates the potential of optimizing intersectoral collaboration for patient care. Although a significant effect of SEKMA on readmissions has not yet been observed, creating a digital ecosystem that connects different health care providers seems to be a promising approach to ensure secure and fast networking of the sectors. The described intersectoral optimization of discharge management provides a structured template for the implementation of a similar local digital care networking infrastructure in other care regions in Germany and other countries with a similarly fragmented health care system., (©Christoph Strumann, Lisa Pfau, Laila Wahle, Raphael Schreiber, Jost Steinhäuser. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 26.03.2024.)

Background: Hypertension is a leading cause of morbidity and mortality if not properly managed. Primary care has a major impact on these outcomes if its strengths, such as continuity of care, are deployed wisely. The analysis aimed to evaluate the quality of care for newly diagnosed hypertension in routine primary care data., Methods: In the retrospective cohort study, routine data (from 2016 to 2022) from eight primary care practices in Germany were exported in anonymized form directly from the electronic health record (EHR) systems and processed for this analysis. The analysis focused on five established quality indicators for the care of patients who have been recently diagnosed with hypertension., Results: A total of 30,691 patients were treated in the participating practices, 2,507 of whom have recently been diagnosed with hypertension. Prior to the pandemic outbreak, 19% of hypertensive patients had blood pressure above 140/90 mmHg and 68% received drug therapy (n = 1,372). After the pandemic outbreak, the proportion of patients with measured blood pressure increased from 63 to 87%, while the other four indicators remained relatively stable. Up to 80% of the total variation of the quality indicators could be explained by individual practices., Conclusion: For the majority of patients, diagnostic procedures are not used to the extent recommended by guidelines. The analysis showed that quality indicators for outpatient care could be mapped onto the basis of routine data. The results could easily be reported to the practices in order to optimize the quality of care., (© 2024. The Author(s).)

Background: Medical decisions are influenced by a variety of factors also by legal requirements and feelings of uncertainty, which results in the term defensive medicine. The aim of the study was to evaluate the influence of fears of perceived legal consequences on the practice of defensive medicine from the perspective of German general practitioners (GPs)., Methods: A cross-sectional study was performed from April to May 2022. GPs were invited via an e-mail newsletter of the Institute for Continuing Education in Family Medicine in the German Association of General Practitioners and via an online platform of the German College of General Practitioners and Family Physicians. The evaluation of legal fears, the general assessment of defensive medicine and reasons for and the frequency of defensive medical measures were surveyed in this study. Beside descriptive analyses, a stepwise linear regression analysis was used to explore potential associations between for the primary outcome variable 'fears of legal consequences' on the practice of defensive medicine., Results: 413 general practitioners with an average age of 50 years (51% female) responded. The majority rated their fears of legal consequences as low to average whereas for almost a third (27%, n = 113) the fears were strong to very strong. Regarding legal fears, the physician-patient-relationship played a fairly to very large role for 48% (n = 198) of the respondents. One third estimated the probability of being sued civilly in the next 10 years as rather high to very high. 47% (n = 193) of the participants assumed that the risk of being sued could mostly to very much be reduced by defensive medicine. Legal self-protection was for 38% of the responders (n = 157) quite frequently to very frequently a reason for acting defensively. Consequently, half of the respondents stated that they performed unnecessary laboratory tests at least once per week and 40% indicated that they referred patients for radiological diagnostics without medical indication once per month., Conclusions: As legal fears have an influence on medical practice and legal self-protection being a frequent reason for defensive behaviour, understanding and knowledge of the law should be improved by legal education at university and further training of post-graduate trainees and practicing physicians should be implemented. Additionally, a more in-depth enlightenment of society about the phenomenon of Protective and Defensive Medicine and its consequences could be a possibility to decrease the perceived fears of legal consequences on the physicians' side., (© 2024. The Author(s).)

Background: Primary care is known to be one of the most complex health care settings because of the high number of theoretically possible diagnoses. Therefore, the process of clinical decision-making in primary care includes complex analytical and nonanalytical factors such as gut feelings and dealing with uncertainties. Artificial intelligence is also mandated to offer support in finding valid diagnoses. Nevertheless, to translate some aspects of what occurs during a consultation into a machine-based diagnostic algorithm, the probabilities for the underlying diagnoses (odds ratios) need to be determined., Objective: Cough is one of the most common reasons for a consultation in general practice, the core discipline in primary care. The aim of this scoping review was to identify the available data on cough as a predictor of various diagnoses encountered in general practice. In the context of an ongoing project, we reflect on this database as a possible basis for a machine-based diagnostic algorithm. Furthermore, we discuss the applicability of such an algorithm against the background of the specifics of general practice., Methods: The PubMed, Scopus, Web of Science, and Cochrane Library databases were searched with defined search terms, supplemented by the search for gray literature via the German Journal of Family Medicine until April 20, 2023. The inclusion criterion was the explicit analysis of cough as a predictor of any conceivable disease. Exclusion criteria were articles that did not provide original study results, articles in languages other than English or German, and articles that did not mention cough as a diagnostic predictor., Results: In total, 1458 records were identified for screening, of which 35 articles met our inclusion criteria. Most of the results (11/35, 31%) were found for chronic obstructive pulmonary disease. The others were distributed among the diagnoses of asthma or unspecified obstructive airway disease, various infectious diseases, bronchogenic carcinoma, dyspepsia or gastroesophageal reflux disease, and adverse effects of angiotensin-converting enzyme inhibitors. Positive odds ratios were found for cough as a predictor of chronic obstructive pulmonary disease, influenza, COVID-19 infections, and bronchial carcinoma, whereas the results for cough as a predictor of asthma and other nonspecified obstructive airway diseases were inconsistent., Conclusions: Reliable data on cough as a predictor of various diagnoses encountered in general practice are scarce. The example of cough does not provide a sufficient database to contribute odds to a machine learning-based diagnostic algorithm in a meaningful way., (©Julia Cummerow, Christin Wienecke, Nicola Engler, Philip Marahrens, Philipp Gruening, Jost Steinhäuser. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 14.12.2023.)

Background: Stratified models of care are valuable for addressing psychosocial factors which influence the outcome of patients with musculoskeletal disorders. Introducing such models in undergraduate training has the potential to propagate this knowledge with evidence and foster its implementation. The objective of this paper is to explore the perception and changes in the fear-avoidance beliefs of physiotherapy students participating in a developed blended learning course on stratified care., Methodology: A mixed-methods with a convenient sample of two consecutive cohorts were given a blended learning course on stratified care for patients with low back pain. The blended learning course comprised scientific rudiments and application of stratified care in clinical practice conceptualised using the KERN' 6-step approach. The exam scores, perceptions, performance on self-reflection-tests and pre- and post-scores on The Tampa Scale for Kinesiophobia for Physiotherapists' (TSK-PT) were obtained. After gaining clinical experience, participants were invited to discuss their clinical experiences and perceptions in workshops. The quantitative data was analysed explorative-descriptively. The qualitative data was analysed following an inductive coding system with constant comparisons., Results: Ninety-one participants consented to the evaluation (mean age = 22.9 ± 1.6 years), 66% were female. Exam scores correlated with time spent in training (r = 0.30) and scores on self-reflection-tests 1 and 2 (r = 0.40 and r = 0.41). Participants in both cohorts described the learning resources as promoting their interest in the subject (72% and 94%), up-to-date (91% and 93%) and helpful (91% and 97%). The fear-avoidance scores for participants decreased from 53.5 (± 9.96) to 40.1 (± 12.4) with a large effect size (d = 1.18). The regression model [F (2, 49) = 1151.2, p < 0.001] suggests that pre-TSK-PT and the interest of participants in the training predicted post-TSK-PT. The workshop participants (n = 62) all worked in clinical practice. Emerging from the analysis were 4 categories (evolving to maturity in practice, perceiving determinants of stratified care, strategising for implementation and adopting an outlook for future practice)., Conclusion: The quality of engagement in learning, training strategy and interest in the subject contributes immensely to learning outcomes. This blended learning course was successful in reducing kinesiophobia and influencing the participants' attitude towards care with the potential of being translated into long-term practice., (© 2023. The Author(s).)

Background: The evaluation and the improvement of the quality of telemedical care become increasingly important in times where this type of care is offered to a broad number of patients more and more. As telemedical care in an offshore setting has already been in use for decades, analyzing the extensive experience of offshore paramedics using telemedical care can help identify determinants of quality. Therefore, the aim of this study was to explore determinants of the quality of telemedical care using the experiences of experienced offshore paramedics., Methods: We conducted a qualitative analysis of 22 semi-structured interviews with experienced offshore paramedics. The results were categorized in a hierarchical category system using content analysis as described by Mayring., Results: All 22 participants were males, having a mean of 3.9 years of experience working with telemedicine support offshore. Generally, participants stated that for them telemedical interaction did not differ much from personal interaction. However, the offshore paramedics personality and way to communicate were mentioned to impact the quality of telemedical care as it influenced the way cases were presented. Furthermore, interviewees described it to be impossible to use telemedicine in cases of an emergency as it was too time-consuming, technically too complex, and lead to cognitive overload as other tasks with higher priority needed their attention. Three determinants of a successful consultation were mentioned: low levels of complexity in the reason for consultation, telemedical guidance training for the teleconsultant physician and for the delegatee., Conclusion: Appropriate indications for telemedical consultation, communication training of consultation partners, and the impact of personality need to be addressed to enhance the quality of future telemedical care., (© 2023. The Author(s).)

Background: Communication is a crucial element of every health care profession, rendering communication skills training in all health care professions as being of great importance. Technological advances such as artificial intelligence (AI) and particularly machine learning (ML) may support this cause: it may provide students with an opportunity for easily accessible and readily available communication training., Objective: This scoping review aimed to summarize the status quo regarding the use of AI or ML in the acquisition of communication skills in academic health care professions., Methods: We conducted a comprehensive literature search across the PubMed, Scopus, Cochrane Library, Web of Science Core Collection, and CINAHL databases to identify articles that covered the use of AI or ML in communication skills training of undergraduate students pursuing health care profession education. Using an inductive approach, the included studies were organized into distinct categories. The specific characteristics of the studies, methods and techniques used by AI or ML applications, and main outcomes of the studies were evaluated. Furthermore, supporting and hindering factors in the use of AI and ML for communication skills training of health care professionals were outlined., Results: The titles and abstracts of 385 studies were identified, of which 29 (7.5%) underwent full-text review. Of the 29 studies, based on the inclusion and exclusion criteria, 12 (3.1%) were included. The studies were organized into 3 distinct categories: studies using AI and ML for text analysis and information extraction, studies using AI and ML and virtual reality, and studies using AI and ML and the simulation of virtual patients, each within the academic training of the communication skills of health care professionals. Within these thematic domains, AI was also used for the provision of feedback. The motivation of the involved agents played a major role in the implementation process. Reported barriers to the use of AI and ML in communication skills training revolved around the lack of authenticity and limited natural flow of language exhibited by the AI- and ML-based virtual patient systems. Furthermore, the use of educational AI- and ML-based systems in communication skills training for health care professionals is currently limited to only a few cases, topics, and clinical domains., Conclusions: The use of AI and ML in communication skills training for health care professionals is clearly a growing and promising field with a potential to render training more cost-effective and less time-consuming. Furthermore, it may serve learners as an individualized and readily available exercise method. However, in most cases, the outlined applications and technical solutions are limited in terms of access, possible scenarios, the natural flow of a conversation, and authenticity. These issues still stand in the way of any widespread implementation ambitions., (©Tjorven Stamer, Jost Steinhäuser, Kristina Flägel. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 19.06.2023.)

Introduction: Climate change is the greatest threat to human health and therefore has a direct impact on the work of physicians. At the same time, the health sector is also an originator of pollutants that burden the climate. The concept of Planetary Health describes, among other things, ways in which the health sector can counter the effects of climate change. Nevertheless, the inclusion of contents on sustainable action in the education of health professionals has not been made mandatory to date. The aim of this study is to answer the question of how an intervention has to be designed so that medical students specifically develop an interest in dealing with the topic on their own., Methods: The intervention consisted ofFor evaluation purposes, a qualitative study with guided focus group interviews of attendees was conducted. The fully transcribed focus group transcripts were analysed using Mayring's structuring qualitative content analysis. Additionally, we checked the semester evaluation for feedback on the intervention., Results: Four focus groups comprising n = 14 medical students (11 female, 3 male) were conducted. Dealing with Planetary Health as a topic during medical education was considered relevant. The partially restrained to negative reaction of the teaching practice staff involved to the checklist had a demotivating effect. A lack of time was given as a further reason for not dealing with the topic independently. Participants suggested integrating specific Planetary Health content in mandatory courses and considered environmental medicine to be especially suited. As a didactic method, case-based working in small groups seemed to be particularly appropriate. In the semester evaluation, we found both approving and critical commentaries., Discussion: Participants considered Planetary Health a relevant topic in the context of medical education. The intervention proved to be of limited use in motivating students to deal with the topic independently. A longitudinal integration of the topic in the medical curriculum seems to be appropriate., Conclusions: From the students' perspective, it is important to teach and acquire knowledge and skills regarding to Planetary Health in the future. Despite a high level of interest, additional offers are not being utilised due to a lack of time and should therefore be made part of the mandatory curriculum, where possible., (Copyright © 2023. Published by Elsevier GmbH.)

Objective: Diabetic retinopathy (DR) may lead to irreversible damage to the eye and cause blindness if diagnosed in its advanced stages. Artificial intelligence (AI) may support screening and contribute to a timely diagnosis. The aim of this study was to evaluate factors that might influence the success of implementing AI-supported devices for DR screenings in general practice., Methods: A questionnaire with modules on attitudes toward digital solutions, technical factors, perceived patient perspectives, and sociodemographic data was constructed and 2100 general practitioners (GPs) in Germany were invited to participate via a personal letter., Results: Two hundred nine physicians participated in the survey (10% response rate, mean age = 54 years, 46% women). Acquisition costs (mean = 1.37), remuneration (mean = 1.46), and running costs (mean = 1.40) were considered particularly relevant in the context of AI-based screening tools. GPs indicated that a mean of €27.00 (SD = 19) was considered to be an appropriate reimbursement for an AI-based screening for DR in their practice. Less relevant factors were availability of a smartphone used in the practice (mean = 2.53) and time until the examination result was available (mean = 2.29). Important technical factors were practicability of the device (mean = 1.27), unproblematic installation of any necessary software (mean = 1.34), and the integrability into the practice information system (mean = 1.44). Considering the patient welfare, physicians rated the accuracy of the examination, omission of pupil dilation, and the duration of the examination as the most important factors. Participants ranked the factors broadening the scope of care, strengthening the primary care (PC) range, and signs of modern medical practice as the most important factors for making an AI-based screening tool attractive for their practice., Conclusions: These findings serve as a basis for a successful implementation of AI-assisted screening devices in PC and might facilitate early screenings for ophthalmological diseases in general practice. The most relevant barriers that need to be overcome for a successful implementation of such tools include clarification of the costs and reimbursement policies., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2023.)

In the wake of the COVID-19 pandemic, video consultation was introduced in general practice in many countries around the world as a solution to provide remote health care to patients. It was assumed that video consultation would find widespread adoption in post-COVID-19 general practice. However, adoption rates remain low across countries in Northern Europe, suggesting that barriers to its use exist among general practitioners and other practice staff. In this viewpoint, we take a comparative approach, reflecting on similarities and differences in implementation conditions of video consultations in 5 Northern European countries' general practice settings that might have created barriers to its use within general practice. We convened at a cross-disciplinary seminar in May 2022 with researchers and clinicians from 5 Northern European countries with expertise in digital care in general practice, and this viewpoint emerged out of dialogues from that seminar. We have reflected on barriers across general practice settings in our countries, such as lacking technological and financial support for general practitioners, that we feel are critical for adoption of video consultation in the coming years. Furthermore, there is a need to further investigate the contribution of cultural elements, such as professional norms and values, to adoption. This viewpoint may inform policy work to ensure that a sustainable level of video consultation use can be reached in the future, one that reflects the reality of general practice settings rather than policy optimism., (©Elisabeth Assing Hvidt, Helen Atherton, Jelle Keuper, Eli Kristiansen, Elle Christine Lüchau, Børge Lønnebakke Norberg, Jost Steinhäuser, Johannes van den Heuvel, Lilian van Tuyl. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 22.05.2023.)

Rationale, Aims and Objectives: Medical decision-making processes in primary care are influenced by defensive medical practice. This involves a high possibility for negative consequences on many levels, for example, patient's health, health care system costs and a crisis of trust in the patient-doctor relationship. Aim of this review was to identify factors of defensive medicine-based decision-making in primary care., Methods: This scoping review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping reviews (PRISMA-ScR) guidelines and included systematic research on MEDLINE, Google Scholar and two German databases for additional grey literature. References provided further literature. Articles in English and German published from 1 January 1982 to 15 June 2022 were assessed., Results: From 911 publications screened, 13 publications [6 qualitative studies and 7 quantitative (3 cross-sectional) studies] were included. In these, four main categories of factors influencing defensive medical practice were identified: (social) media, patients adopting a consumer attitude, health care system based working conditions and physician's tolerance for uncertainty. Pressure deriving from these four different sources is exerted on the general practitioner and may result in a defensive medical decision behaviour., Conclusions: Four categories on influencing factors of defensive medicine could be identified. Strategies to tolerate uncertainty should be trained in under- and postgraduate training., (© 2022 The Authors. Journal of Evaluation in Clinical Practice published by John Wiley & Sons Ltd.)

Introduction : Successful home care for people living with dementia (PLwD) allows them to live in their own home environment for as long as possible. Current findings indicate a need for further development of medical and nursing knowledge and skills in evidence-based collaborative care for these patients. Aim : To identify specifics of inter-professional care for PLwD and training needs of home care nurses and general practitioners involved in care. Method : A multi-perspective qualitative study was conducted, comprising focus groups as well as individual interviews. Focus groups and interviews followed a semi-structured topic guide. Interview data was digitally recorded and transcribed verbatim, followed by a thematic framework analysis. Results : The sample consisted of nine nurses, one medical assistant, three general practitioners and nine family caregivers of PLwD. Five themes related to inter-professional home care were inductively developed: challenges in outpatient dementia care, challenges in collaboration, insufficient healthcare infrastructure, competencies needed in dementia care, and training requirements. Challenges were a lacking flow of information as well as continuity and organization of care. Home care nurses and family caregivers complained about missing communication skills in health professionals involved in the care of PLwD. Conclusions : The interviews revealed heterogeneous training needs of home care nursing staff and general practitioners that can be addressed by an inter-professional training course.

Introduction: Since the patient-doctor relationship (PDR) plays a crucial role in patient primary health care and management, the evaluation of the PDR from both, the patients' and primary care physicians', perspectives is an important approach to improve the quality of primary care. However, although there are a variety of questionnaires surveying the patients' view of the PDR, only few consider the physicians' perspective. The purpose of this study was to develop a questionnaire that adds the physicians' perspective to an existing PDR instrument and thus enables a mutual assessment of the relationship., Methods: This study was embedded in a German project aiming at enhancing the adherence in patients with hypertension. Patients and primary care physicians were asked to complete a questionnaire concerning their PDR. The Patient-Doctor Relationship Questionnaire (PDRQ-9) was used to assess the patients' perspective. For the physicians, the PDRQ-9 items were adapted to the physicians' perspective resulting in the GP-Patient Relationship Questionnaire (GPPR). The Helping Alliance Questionnaire (HAQ) was used for external validation., Results: A total of 60 physician questionnaires and 50 matched pairs of questionnaires from physicians and patients were included in the analyses. Within the analysis, notable deviations were found for one item, nevertheless the calculated Cronbach's α of 0.89 showed a high internal consistency of the 9-item questionnaire. External validation showed a high correlation of the GPPR with the HAQ, confirming the good psychometric properties demonstrated for the overall instrument., Discussion: Overall, this initial validation study revealed good psychometric properties of the GPPR. A retest will be performed in the course of the overall project to confirm the reliability of the newly developed questionnaire., Conclusion: A new questionnaire to assess the physicians' perspectives on the PDR was successfully developed to improve adherence-dependent processes of quality improving in primary care., (Copyright © 2023. Published by Elsevier GmbH.)

Aim: The German ban on remote treatment was relaxed in 2018. The SARS-CoV-2 pandemic ultimately ensured a surge in the implementation of video consultations as part of telemedicine in primary care. However, the question of how the quality of this form of care is represented is currently unanswered. The aim of this review was to identify criteria for assessing the quality of video consultations in primary care., Methods: As part of this review, a literature search was carried out in the databases PubMed, Web of Science, Google Scholar, Open Gray and Google. We searched for literature on quality criteria or quality indicators for telemedicine. German and English-language literature was included, there was no limit on publication date., Results: A total of 14 publications were included in the review. Out of the quality criteria identified, 13 quality indicators were derived. Of these, seven were for structural quality, two for process quality and four indicators for outcome quality. For instance, the switch to face-to-face treatment for those cases for which it was required, staff qualifications and access to this type of care were identified as possible indicators., Conclusion: The quality indicators proposed in this article enable a structured evaluation of the quality of video consultations in primary care through their measurability. Further development of these indicators in order to define threshold values for the stated goals appears to be warranted., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Background: There is an increasing number of patients that do not make a rapid or full recovery from a SARS-CoV-2 infection, the Coronavirus Disease 2019 (COVID-19) and suffer from the so-called "long-COVID" or post-acute sequelae of COVID-19 (PASC). The long-term implications for health services are expected to be substantial. The objective of this analysis was to estimate the utilization of outpatient services from primary and secondary care. Further, we evaluated the multidisciplinary ambulatory care management of PASC patients in Germany., Methods: All members of the Physician network "MEDI Baden-Württemberg e.V.", i.e., 1,263 primary care physicians (PCPs) and 1,772 specialists working in secondary care were invited to participate in a questionnaire surveying routine data regarding the general care situation at the physician practice level of patients suffering from PASC. Bivariate analyses were applied to consider potential differences between primary and secondary care., Results: In total, 194 physicians participated in this survey (response rates of 9.6% (primary care) and 4.1% (secondary care). On average, each physician treated 31.9 PASC patients. Most PASC patients (61.2%) had three or more long-COVID symptoms. On average, 10.6 PASC patients visited a physicians' practice per quarter. The additional consulting effort for treating PASC patients was 34.1 min (median: 20 min) and higher in primary care. Most PCPs (71.1%) integrated secondary care in the treatment of their PASC patients. Less than half of the PASC patients (42.0%) sought secondary care with a referral from primary care. 5.7 patients visited the physicians' practices per week, who were concerned about suffering from PASC without any following medical confirmation. This caused an average additional effort for the physicians of 17.5 min per visit. There were no differences between rural and urban areas., Conclusion: Our results reveal that there is a substantial additional consulting effort for treating PASC patients that is especially high in primary care. The additional consulting effort results from the consultation of a particular high number of patients that are concerned about suffering from PACS without a following medical confirmation. To guarantee a high quality and adequate provision of care for a potentially further increasing number of concerned patients, the ambulatory health services should be strengthened and adequately compensated., (© 2023. The Author(s).)

Background: The MAAS Global ( Maastricht History-taking and Advice Scoring List ) is an internationally widely-used instrument in under- and postgraduate medical education. The focus is on the assessment of medical communication and clinical skills. The assessment tool, which has also been used in Germany since 2015, has a high-quality design (e.g. comprehensible structure, appropriate complexity), good psychometric properties and is very user-friendly. An update of MAAS Global, MAAS 2.0, was published in March 2021 with a new and greater focus on context and the formative., Method: The revised version of the MAAS 2.0 assessment sheet was translated into German with the authors' permission. Open questions were discussed with the revision process project manager., Results: The revision was carried out with a view to focusing on the patient's frame of reference, removing ambiguities identified previously while using MAAS Global, and closer alignment with the underlying Calgary-Cambridge model. Furthermore, the scale used for the evaluation was modified and now uses a formative evaluation range without grade-related classification., Conclusion: With the content reorientation of MAAS Global to MAAS 2.0, and the associated focus on frame of reference, context, the formative, the revision presented here sets new priorities for future evaluations in the context of under- and postgraduate medical education and the assessment of medical patient communication in general., Competing Interests: The authors declare that they have no competing interests., (Copyright © 2023 Stamer et al.)

Background: Stratified care approach involving use of the STarT-Back tool to optimise care for patients with low back pain is gaining widespread attention in western countries. However, adoption and implementation of this approach in low-and-middle-income countries will be restricted by context-specific factors that need to be addressed. This study aimed to develop with physiotherapists, tailored intervention strategies for the implementation of stratified care for patients with low back pain., Methods: A two-round web-based Delphi survey was conducted among purposively sampled physiotherapists with a minimum of three years of clinical experience, with post-graduation certification or specialists. Thirty statements on barriers and enablers for implementation were extracted from the qualitative phase. Statements were rated by a Delphi panel with additional open-ended feedback. After each Delphi round, participants received feedback which informed their subsequent responses. Additional qualitative feedback were analysed using qualitative content analysis. The criteria for consensus and stability were pre-determined using percentage agreement (≥ 75%), median value (≥ 4), Inter-quartile range (≤ 1), and Wilcoxon matched-pairs test respectively., Results: Participants in the first round were 139 and 125 of them completed the study, yielding a response rate of 90%. Participants were aged 35.2 (SD6.6) years, and 55 (39.6%) were female. Consensus was achieved in 25/30 statements. Wilcoxon's test showed stability in responses after the 5 statements failed to reach consensus: 'translate the STarT-Back Tool to pidgin language' 71% (p = 0.76), 'begin implementation with government hospitals' 63% (p = 0.11), 'share knowledge with traditional bone setters' 35% (p = 0.67), 'get second opinion on clinician's advice' 63% (p = 0.24) and 'carry out online consultations' 65% (p = 0.41). Four statements strengthened by additional qualitative data achieved the highest consensus: 'patient education' (96%), 'quality improvement appraisals' (96%), 'undergraduate training on psychosocial care' (96%) and 'patient-clinician communication' (95%)., Conclusion: There was concordance of opinion that patients should be educated to correct misplaced expectations and proper time for communication is vital to implementation. This communication should be learned at undergraduate level, and for already qualified clinicians, quality improvement appraisals are key to sustained and effective care. These recommendations provide a framework for future research on monitored implementation of stratified care in middle-income countries., (© 2023. The Author(s).)

Background: Routinely collected health data from ambulatory care providers offer a wide range of research opportunities. However, the access is often (e.g., technically) hindered, particularly in Germany. In the following, we describe the development of an infrastructure for the analysis of pseudonymized routine data extracted from primary care practices in Germany. Further, we analyze the impact of the outbreak of SARS-CoV-2 on the utilization of primary care services for patients with type 2 diabetes mellitus (DM type 2)., Methods: In this retrospective cohort study, routine data were extracted from nine private primary care practices before and since the outbreak of SARS-CoV-2 in Germany. The sample consisted of patients who were treated between 2016 and 2022 in one of the participating practices. The effects of the outbreak on the frequency of practice visits and the disease course of DM type 2 patients were analyzed by means of bivariate and multivariate analyses., Results: The developed infrastructure offers an analysis of routine data from outpatient care within 24 h. In total, routine data of 30,734 patients could be processed for the analyses with 4182 (13.6%) patients having a diagnosed DM type 2 and 59.0% of these patients were enrolled in a disease management program (DMP). In the multivariate analysis, there was a significant negative effect of the SARS-CoV-2 outbreak on utilization of outpatient services of patients with DM type 2 disease. This decrease was less pronounced among DMP patients. The glycated haemoglobin level (HbA1c) has not changed significantly., Conclusions: The study showed that the analysis of routine data from outpatient care in Germany is possible in a timely manner using a special developed electronic health record system and corresponding software. The significantly negative effect of the SARS-CoV-2 outbreak on utilization of outpatient services of patients with DM type 2 disease was less pronounced among DMP patients. Two years after the start of the Covid pandemic a significantly worsened course of illness cannot be observed. However, it must be taken into account that the observation period for clinically relevant outcomes is still relatively short., (© 2022. The Author(s).)

(1) Background: Telemedical applications (TAs) that are centered around General practitioners' (GP) practices could be beneficial for patients in rural areas in order to better their access to care. This could become more and more relevant as specialists favor practicing in more urban regions, leaving GPs as the first medical contact of patients in rural areas. (2) Methods: Three TAs, one synchronous, one asynchronous and one used in delegation were implemented and evaluated in ten GP practices and two specialists' practices in rural areas of northern Germany. (3) Results: Overall satisfaction with the TAs was generally high. GPs as well as specialists were especially satisfied with asynchronous TAs. A number of valuable "Lesson learned" were obtained and can be used as recommendations for further studies, e.g., taking time to identify market-ready technologies prior to implementation, developing dedicated trainings for users, and preparation of a technical support plan. Overall, the benefits of the TAs were rated high for the patients by the medical professionals. (4) Conclusion: Especially asynchronous TAs that are based on existing technology can be successfully implemented into a developing digital health care system such as the one in Germany. The impact on treatment of those TAs needs to be further investigated.

Background: The GERDA ("Protected e-prescription service for pharmacies") project of the Chamber of Pharmacists (LAK) and Pharmacists Association (LAV) of the federal state of Baden-Wuerttemberg provided the opportunity to prescribe medications within the telemedical portal "docdirekt" that is operated by the Association of Statutory Health Insurance Physicians of Baden-Wuerttemberg. Against this background, the aim of the study was to explore and prioritize barriers and enablers among pharmacists to participate in a medical supply system that includes electronic prescriptions (e-prescriptions). Based on these determinants, recommendations for optimizing the successful implementation of similar care offers were derived., Method: A mixed methods design was chosen to explore and prioritize the determinants. In the first step, determinants for participation in an electronic prescribing system were explored by means of individual interviews of docdirekt tele-physicians, primary care physicians and pharmacists. In a second step, these determinants were prioritized through a quantitative survey of pharmacists., Results: Out of the 523 pharmacists that answered the questionnaire, more than half were willing to participate in an e-prescription system, while 8.5% excluded future participation. A total of 18 determinants for the e-prescription system participation could be explored. The protection of the free pharmacy choice for the patients was identified as the most important determinant, followed by the option of a correction function for e-prescriptions (e. g. to avoid retaxing or medication errors), the integration of the e-prescription into the existing pharmacy IT system and the statutory exclusion of direct contracts with online pharmacies. Time savings and possibly higher remunerations were rated as less relevant., Conclusion: More than half of the pharmacies surveyed stated that they wanted to participate in an e-prescription system. Widespread introduction of e-prescriptions in planned for January 2022. Successful implementation of this move will be facilitated if the identified determinants are taken into consideration by politics, software developers and associations., Competing Interests: Die Autoren geben keinen Interessenkonflikt an. Die Studie wurde finanziell durch die Landesapothekerkammer Baden-Württemberg und das Ministerium für Soziales und Integration Baden-Württemberg unterstützt. Die Studie erfolgte weisungsunabhängig., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Background: To ease the burden for family caregivers healthcare concepts are urgently needed. The healthcare concept continuous care in a regional network (RubiN) offers a care and case management in physician networks for geriatric patients and aims to relieve family caregivers. The aim of the study was to develop and to test the psychometric properties of a questionnaire that evaluates the satisfaction and acceptance of the healthcare provided by case management (CM) from the perspective of family caregivers., Methods: A mixed methods design was used to develop the questionnaire based on qualitative interviews, a literature search and own project experiences. After a pilot run the subsequent data acquisition took place in the participating RubiN physician networks from May to August 2020. Each of the 5 participating networks received a set of 50 questionnaires for family caregivers. The psychometric properties of the questionnaire were evaluated., Results: The questionnaire consisted of 11 items. A total of 137 family caregivers participated in the survey (response rate 55%). Overall, the family caregivers were very satisfied (78.1%) with the care offered. There were only a few missing values in the data. The 11 items in the questionnaire loaded on 2 factors. The first factor called effects from coordination showed an internal consistency of 0.843 and for the second factor called accessibility an internal consistency of 0.683 was observed., Conclusion: The questionnaire with 11 items is characterized by its brevity and includes the acceptance and satisfaction of the care elements offered for family caregivers in a geriatric CM., (© 2021. The Author(s).)

Purpose: One of the reasons for postgraduate trainees not to choose working in a rural area is uncertainty related to the lack of competencies. The aim of this study was to investigate the concept of uncertainty by measuring competencies and to examine the psychometric properties of an instrument that measures competencies related to uncertainty in the self-assessment of postgraduate trainees in family medicine., Patients and Methods: A questionnaire was created based on pre-existing instruments. It was distributed to participants of postgraduate training seminars in the federal states of Baden-Württemberg and Schleswig-Holstein, Germany in 2016. Descriptive statistics and a partial correlation analysis were calculated for measuring the degree of association between year of postgraduate training and items' responses. Psychometric properties were assessed by calculating descriptive item analysis, factor analysis and internal consistency., Results: The response rate was 85% (105/124). More than one-fifth of the participants stated to show only seldom or sometimes the following skills: ability to balance work and life (N=25, 24%), letting a mild disorder run its own way (N=24, 23%) and ability to conduct interventions that decreased aggression from the patient (N=22, 21%). More than half of the participants felt (very) insecure in performing routine child check-ups, the application of a below elbow backslab and the partial removal of a toenail. Nine out of 21 items showed positive statistically significant correlation between level of competence and progress in training. Factor analysis led to a final instrument with 12 items (Cronbach's α=0.736) and a three-factor-structure: "doctor well-being and resilience", "communication" and "skills"., Conclusion: In order to reduce uncertainty with all its consequences, a focus on teaching of competencies regarding the physicians' well-being and resilience, communication and skills has to be continued in postgraduate training., Competing Interests: The authors report no conflicts of interest in this work., (© 2022 Flägel et al.)

Fear of flying can lead to restrictions in private but also in professional life. Different treatment approaches are available to handle fear of flying. Of these, coaching could be one possible treatment method. However, evidence is rare and the aim of this study was to evaluate descriptive effect of wingwave® coaching on a mild form of fear of flying. Coaching was delivered twice before the first flight and once after the first flight. The interventions were conducted between December 2016 and May 2017. Four people with fear of flying participated in the study. As measurement tools, satisfaction with life scale and 'Fear of Flying Scale' (FFS) were used at each of the measurement points. The measurement of fear of flying using the FFS measures showed a reduction in all four individuals. The participants also revealed a benefit in the sub-scales Anticipation, Flying and Turbulence. Our study indicates a positive impact of wingwave® coaching on dealing with a mild form of fear of flying.

Diabetic retinopathy is a microvascular complication of diabetes mellitus that is usually asymptomatic in the early stages. Therefore, its timely detection and treatment are essential. First pilot projects exist to establish a smartphone-based and AI-supported screening of DR in primary care. This study explored health professionals' perceptions of potential barriers and enablers of using a screening such as this in primary care to understand the mechanisms that could influence implementation into routine clinical practice. Semi-structured telephone interviews were conducted and analysed with the help of qualitative analysis of Mayring. The following main influencing factors to implementation have been identified: personal attitude, organisation, time, financial factors, education, support, technical requirement, influence on profession and patient welfare. Most determinants could be relocated in the behaviour change wheel, a validated implementation model. Further research on the patients' perspective and a ranking of the determinants found is needed.

Background: The increase of centralization developments in primary and secondary care practices may cause the organizational needs to increase as well, as the practices grow in size. This continuous change is observed in different stages in various countries since, from the perspective of a physician, it is reinforced by the benefits it adds to flexible work configuration, professional exchange and specialization. However, in order to benefit from the joint practice system, the proper managerial skills of practice managers are required, as doctors are not naturally prepared to fulfill such tasks. This study thus aims to gain insight into physicians' views in group practices and acquire a greater understanding of expectations towards practice management and the emerging role of practice managers (PM)., Methods: A cross-sectional study design was employed which utilized an anonymous online questionnaire. In total, 3,456 physicians were invited to participate in the study between February 8 th and March 17 th 2021 by the Association of Statutory Health Insurance Physicians of Baden-Württemberg, Germany. Bivariate and multivariate analyses were applied to characterize the expectations of physicians towards practice management., Results: The survey yielded 329 replies (9,5%). 50% of the participating practices already had a PM employed. In general, these practices were larger than practices without a PM. Most physicians (85%) considered a medical background to be essential for the task of a PM. While practices without a PM considered it important for PMs to have medical qualifications, practices with a PM favored qualifications in business administration. 77.2% of physicians preferred to educate and recruit PMs out of their current practice staff. Competence in organizational tasks, such as coordination of tasks and quality management, was considered to be an essential skill of a PM and had the highest agreement levels among those surveyed, followed by staff management of non-physicians, billing, bookkeeping, staff management of physicians and recruiting. Based on multivariate regression analysis, larger practices valued the role of a PM more and were more likely to employ a PM. Notably, the effect that size had on these items was more substantial for generalists than specialists., Conclusions: The benefits and importance of PMs as well as the potential for delegation are recognized, in particular, by larger practices. The positive feelings that physicians who already employ PMs have towards their contribution to ambulatory care are even more significant. Pre-existing medical support staff has been identified to be the most desirable candidates for taking on the role of PM., (© 2022. The Author(s).)

Background: Stratified care has the potential to be efficient in addressing the physical and psychosocial components of low back pain (LBP) and optimise treatment outcomes essential in low-income countries. This study aimed to investigate the perceptions of physiotherapists and patients in Nigeria towards stratified care for the treatment of LBP, exploring barriers and enablers to implementation., Methods: A qualitative design with semistructured individual telephone interviews for physiotherapists and patients with LBP comprising research evidence and information on stratified care was adopted. Preceding the interviews, patients completed the Subgroups for Targeted Treatment tool. The interviews were recorded, transcribed and analysed following grounded theory methodology., Results: Twelve physiotherapists and 13 patients with LBP participated in the study (11 female, mean age 42.8 (SD 11.47) years). Seven key categories emerged: recognising the need for change, acceptance of innovation, resistance to change, adapting practice, patient's learning journey, trusting the therapist and needing conviction . Physiotherapists perceived stratified care to be a familiar approach based on their background training. The prevalent treatment tradition and the patient expectations were seen as major barriers to implementation of stratified care by the physiotherapists. Patients see themselves as more informed than therapists realise, yet they need conviction through communication and education to cooperate with their therapist using this approach. Viable facilitators were also identified as patients' trust in the physiotherapist and adaptations in terms of training and modification of the approach to enhance its use., Conclusion: Key barriers identified are the patients' treatment expectations and physiotherapists' adherence to the tradition of practice. Physiotherapists might facilitate implementation of the stratified care by communication, hierarchical implementation and utilisation of patients' trust. Possibilities to develop a consensus on key strategies to overcome barriers and on utilisation of facilitators should be tested in future research., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Introduction: The history of the use of telemedicine in maritime medicine dates back to the 1930s. In the early 2000s, the German Navy built up a telemedicine network which today is installed in all ships and provides a connection to the medical infrastructure ashore. The objective of this study was to optimize the implementation of telemedicine based on the experience gained in the German Navy. For this purpose, qualitative and quantitative methods were used to identify determinants which affect the use of telemedicine in order to determine whether there is any need for optimization., Methods: The study was conducted using a mixed methods design. First, guideline-based interviews were conducted with Navy medical officers who had been recruited via various email distribution lists. The interviews were then transcribed and coded. In an analysis, deductive and inductive categories were derived from the codes. Hypotheses were deduced from the interviews, too, and used to develop a questionnaire.Besides the medical officers, other Navy medical personnel with experience in the field of telemedicine took part in the survey. The study was concluded by a descriptive analysis of the quantitative data., Results: The analysis of the interviews revealed that a regular use of telemedicine workstations increased the users' confidence and, in their opinion, improved medical treatment. Technical and organizational problems posed obstacles, which increased the use of partly insecure alternatives. A proper technical support was regarded as a precondition for effectively using telemedicine.The results of the quantitative analysis showed that consultation was mainly sought for dermatological (46%), surgical (24%), and internal (22%) conditions., Conclusion: The study revealed determinants for the use of telemedicine in the German Navy. Factors improving the motivation of the users should be strengthened in order to optimize the use of telemedicine. Furthermore, it can be assumed that a successful implementation will be supported by reducing or eliminating obstacles. The findings on the main reasons for seeking medical advice could be taken into account in the further planning of specific training., (© The Association of Military Surgeons of the United States 2021.)

As use of complementary medicine (CM) is increasing, health professionals may require proper training in CM to offer evidence-based advice to their patients. The aim of this study was to explore interprofessional collaboration (IPC) in CM in order to gain a comprehensive overview of determinants and to facilitate the definition of objectives for an undergraduate interprofessional educational module. Pursuant to a sequential mixed-methods approach, focus groups and individual interviews with health professionals, who actively use CM in patient care, were conducted. All hospital employees at the University Hospital Lübeck, Germany, were asked to complete an online questionnaire that was based on the previously obtained qualitative results. The interviews with 20 participants revealed four main themes: profession-specific aspects, communication, health care system-associated factors, and the influence of CM on interprofessional dynamics. An analysis of the 157 responses in the online questionnaire showed that team meetings (n = 124, 79%) were most frequently stated as promoting IPC. In binary regression analyses, nursing (OR = 6.17 [2.02-18.84]) and medical professions (OR = 3.77 [1.27-11.18]) predicted evidence-based care as enabler for IPC. Hence, teaching professional competencies and an equal understanding of evidence-based medicine seems necessary to promote IPC within CM.

Background: In many countries, the number of applicants to medical schools exceeds the number of available places. This offers the need, as well as the opportunity to medical schools to select those applicants most suitable for later work as a doctor. However, there is no generally accepted definition of a 'good doctor'. Clinical competencies may serve as surrogates. The aim of this study was to compare medical students in Germany selected based either on their pre-university grade point average alone or based on the result of a university-specific selection procedure regarding their clinical competencies with an emphasis on family medicine in the later years of training., Methods: We used the 'Allgemeinarztbarometer Ausbildung' (Undergraduate Family Medicine Barometer), an instrument developed to assess clinical competencies with an emphasis on family medicine, to compare students in the pre-university grade point average admission-quota and the university-specific selection procedure admission-quota in the fifth year of training. Students were judged by their supervising general practitioners after a two-week practical course. Competencies were rated on a five-point Likert-scale (1 = 'totally agree' i.e. the student is very competent to 5 = 'totally disagree' i.e. the student is not competent at all)., Results: We included 94 students (66% female). Students in the university-specific selection procedure quota (n = 80) showed better mean scores in every item of the Undergraduate Family Medicine Barometer. We found a statistically significant difference between the two groups for the item assessing communication skills (M [university-specific selection procedure quota] = 1.81, SD = 0.84 vs. M [pu-GPA quota] = 2.38, SD = 0.96; t[91] = -2.23, p = .03; medium effect size). Logistic regression revealed no statistically significant age or gender contribution., Conclusions: Despite the small sample-size, our results indicate, that students selected via an university-specific selection procedure show better communicative competencies in the later years of training., (© 2022. The Author(s).)

Background: Due to the COVID-19 pandemic, the Objective Structured Clinical Examination (OSCE) examinations were cancelled in the short term. This project described how to offer medical students an alternative assessment at Miller's competence level of "shows how"., Methods: Students produced videos in which they can be seen performing various physical examinations related to family medicine consultations. Trained assessors rated the videos uploaded to the learning platform and gave verbal feedback if requested., Results: The grading (65 "very good" and 38 "good") was very mild. Twelve per cent of the students requested verbal feedback. Their evaluation of the procedure was mixed. The evaluators consistently assessed their task and the process as positive. Technically, the video-based assessment could be implemented without any problems., Conclusions: The short-term implementation of a video-based assessment in the context of medical education proved to be feasible. It could serve not only as an emergency solution under a pandemic, but also as an additional opportunity for formative feedback in the future., (© Deutscher Ärzteverlag 2022.)

Background: Offshore industries operate all around the world in diverse and remote environments. The use of telemedicine to ensure up-to-date medical care for thousands of people offshore has been common practice for decades. Thus, in this setting, extensive experiences with this type of health care delivery have already been gathered, while in other settings this is just beginning. However, the quality of telemedical care on offshore installations is rarely reported yet. The objective of this review was to explore published literature with regards to the following questions: Have any Quality Indicators (QIs) been published for measuring the quality of telemedical care on offshore installations or are there identifiable items that could be used as such QIs?, Methods: We conducted a comprehensive Scoping Review (PRISMA-ScR) of the published literature using the databases MEDLINE, Cochrane Library, Web of Science (Core Collection), and Google Scholar. Search results were read and QIs or findings from which QIs could be derived were classified according to the dimensions of quality established by Donabedian (structure, process, or outcome QIs)., Results: The search returned 10,236 non-recurring articles, 45 of which were full-text screened and 15 of which were included in this review. Types of publications were heterogenous. No QIs for the quality of telemedical care offshore have been published yet. Findings that could be the basis for QIs focused on structure quality (11 QIs) followed by process quality (11 QIs), while outcome quality was less common (1 QI)., Conclusion: Currently, although years of experience with telemedical care on offshore installations exist, there is a paucity of research on a solid data base regarding the quality of telemedical care offshore. The authors derived a list of 24 possible QIs from the findings of the publications for further validation. This could be the basis for implementation and definition of QIs in this and in similar remote settings., (© 2021. The Author(s).)

Background: Flatfoot is characterised by the falling of the medial longitudinal arch, eversion of the hindfoot and abduction of the loaded forefoot. Furthermore, flatfoot leads to a variety of musculoskeletal symptoms in the lower extremity, such as knee or hip pain. The standard conservative treatment for flatfoot deformity is exercise therapy or treatment with foot orthoses. Foot orthoses are prescribed for various foot complaints. However, the evidence for the provision of foot orthoses is inconsistent. The aim of this systematic review is to synthesize the evidence of foot orthoses for adults with flatfoot., Methods: A computerized search was conducted in August 2021, using the databases PubMed, Scopus, Pedro, Cochrane Library, and the Cochrane Central Register of Controlled Trials. Intervention studies of any design investigating the effects of foot orthoses were included, apart from case studies. Two independent reviewers assessed all search results to identify eligible studies and to assess their methodological quality., Results: A total of 110 studies were identified through the database search. 12 studies met the inclusion criteria and were included in the review. These studies investigated prefabricated and custom-made foot orthoses, evaluating stance and plantar pressure during gait. The sample sizes of the identified studies ranged from 8 to 80. In most of the studies, the methodological quality was low and a lack of information was frequently detected., Conclusion: There is a lack of evidence on the effect of foot orthoses for flatfoot in adults. This review illustrates the importance of conducting randomized controlled trials and the comprehensive development of guidelines for the prescription of foot orthoses. Given the weak evidence available, the common prescription of foot orthoses is somewhat surprising., (© 2021. The Author(s).)

Background: In Germany, family physicians care for about 85% of the patients infected with SARS-CoV-2. The geographic distribution of the first wave in 2020 was heterogeneous, and each federal state experienced different percentages of patients that died from COVID-19. Each of the 16 federal states implemented its own regulation about medical care for SARS-CoV-2 infected patients. Against this background, the objective of this analysis was to gather experiences made by primary care physicians managing SARS-CoV-2 infected patients during the first wave in March 2020 and to clinically characterize these patients., Methods: In total, 5,632 physicians were invited to participate in an online questionnaire surveying routine data regarding the general care situation at the physician practice level and the care for patients infected with SARS-CoV-2. Bivariate and multivariate analyses were applied to characterize treatment experiences and to identify patient characteristics predicting the course of disease., Results: 132 family physicians from all German federal states (except from Berlin) participated in this analysis (response rate 2.3%) and provided routine care data for 1,085 patients. Information from 373 of these patients were provided in greater detail. On average, each physician treated 8.5 patients infected with SARS-CoV-2. About 15% of the physicians used video consultations to communicate with their infected patients. More than 82% made positive experiences with the exceptional regulation to provide a certificate of incapacity to work by telephone. Half of the physicians faced equipment insufficiencies due to a lack of protective gear, and in 10% of the practices, the staff themselves acquired SARS-CoV-2 infection. Greater numbers of SARS-CoV-2 cases treated in a practice translated into higher odds for members of the practice to get infected (odds ratio (OR) 1.03, 95% CI [1.01;1.06]). Older persons, males and patients in rural areas had higher odds of a severe course of disease., Conclusions: Our results show that a large percentage of primary care physicians additionally managed their COVID-19 patients remotely by telephone or video during the outbreak, while also being at a higher risk for SARS-CoV-2 infection. Further, the increased severity in rural areas underlines the importance of strong primary health care in order to enable hospitals to concentrate on critically ill patients., (Copyright © 2021. Published by Elsevier GmbH.)

Background: Telemedicine offers additional ways of delivering medical care, e.g., in primary care in rural areas. During the last decades, projects including telemedicine are being implemented worldwide. However, implementation of telemedicine is in some countries, e.g., Germany somewhat slower compared to northern European countries. One important part of successful implementation is to include the citizen perspective. The aims of this study were to explore the perception of representatives of the local government regarding telemedicine in the context of a perceived GP shortage and to tailor future telemedicine offers according to these perceived needs., Methods: Considering the multidisciplinary assessment suggested by the Model for Assessment of Telemedicine a questionnaire with 19 questions was developed by identifying determinants of telemedicine out the literature. After pre-testing, the questionnaire was sent to all 2199 mayors from the federal states of Schleswig-Holstein (North Germany) and Baden-Württemberg (South Germany) as representatives of the citizens (cross- sectional study; full population survey). The final questionnaire contained sections for socio-demographic data, telemedicine and perceived GP shortage. All responses from November 2018 until 2019 were included and analyzed descriptively., Results: The response rate was 32% (N = 699), of which 605 were included in the analysis. A majority of the participants stated they live in a rural area and 46% were in the office for up to 8 years. The mayors had predominantly a positive perception about telemedicine (60%) and 76% of them stated, their community would benefit from telemedicine. A GP shortage was reported by 39% of the participants. The highest risk of telemedicine was seen in misdiagnosing. In case of an emergency situation 291 (45%) of the participants considered data privacy as not as relevant. Mayors from a community with a perceived GP shortage had a more negative perception regarding telemedicine., Conclusion: The acceptance of telemedicine is rapidly rising compared to former studies. Communities with a perceived GP shortage had a more negative perception. Barriers like data security concerns were seen as less important in case of an emergency. The highest risk of telemedicine was seen in misdiagnosing. These findings need to be considered in designing future telemedicine offers., (© 2021. The Author(s).)

Background: Diabetic retinopathy (DR) affects 10-24% of patients with diabetes mellitus type 1 or 2 in the primary care (PC) sector. As early detection is crucial for treatment, deep learning screening methods in PC setting could potentially aid in an accurate and timely diagnosis., Purpose: The purpose of this meta-analysis was to determine the current state of knowledge regarding deep learning (DL) screening methods for DR in PC., Data Sources: A systematic literature search was conducted using Medline, Web of Science, and Scopus to identify suitable studies., Study Selection: Suitable studies were selected by two researchers independently. Studies assessing DL methods and the suitability of these screening systems (diagnostic parameters such as sensitivity and specificity, information on datasets and setting) in PC were selected. Excluded were studies focusing on lesions, applying conventional diagnostic imaging tools, conducted in secondary or tertiary care, and all publication types other than original research studies on human subjects., Data Extraction: The following data was extracted from included studies: authors, title, year of publication, objectives, participants, setting, type of intervention/method, reference standard, grading scale, outcome measures, dataset, risk of bias, and performance measures., Data Synthesis and Conclusion: The summed sensitivity of all included studies was 87% and specificity was 90%. Given a prevalence of DR of 10% in patients with DM Type 2 in PC, the negative predictive value is 98% while the positive predictive value is 49%., Limitations: Selected studies showed a high variation in sample size and quality and quantity of available data., Competing Interests: The authors have declared that no competing interests exist.

Objective: Since 2006, with the opening of emergency practices (EP) in Germany, out-of-hours patient care has been carried out by general practitioners. Additionally, emergency departments (ED) of the hospitals ensure acute care. Thus, optimal coordination of care is a much discussed subject. The aim of this study was to provide reasons for encounter and subjective reasons to visit each of these institutions., Methods: In a mixed method trial, patients with non-urgent conditions (Manchester Triage System level 4 and 5) were interviewed in 2 ED in Schleswig-Holstein and 2 EP in Baden-Württemberg regarding their reasons for encounter from July 2015 to August 2016 during the out of hours primary care practices. Data collection was carried out using a paper-based questionnaire and a semi-structured interview. The statistical program SPSS was used for descriptive analysis, text data analysis was carried out with the method of qualitative content analysis., Results: In total, 398 patients were interviewed. Most frequently, reasons for encounter in ED and EP were related to musculoskeletal complaints (39%, n=116 and 23%, n=23, respectively). Within technical examination services, the laboratory diagnostics were used as a priority in ED (59%, n=175). In the EP, one patient (2%) underwent laboratory diagnostics. The main reasons for encounter in both facilities were increasing complaints (50%, n=147 in ED; 70%, n=70 in EP) and a desire for quick diagnosis (73%, n=217 in ED; 48%, n=48 in EP). In total, 112 patients (28%) had a medication plan, and 67 (60%) brought it into the facility. Two-thirds of ED patients (n=197) were handed over to outpatient care. In EP, 89% (n=89) continued as outpatient. Qualitative content analysis revealed similar complaint categories in both facilities, but with significant differences in the severity and experienced urgency. In both facilities, patients expected to have their symptoms clarified. In ED, the desire for a rapid and specific diagnosis was expressed more frequently., Conclusion: Indications for medical treatment were seen in most consultations in both care facilities. There was a distinction between the ED and EP in the urgency of the consultations., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenskonflikt besteht., (Thieme. All rights reserved.)

Background: Germany is facing a shortage of primary care physicians (general practitioners, GPs). To improve post-graduate training in general practice, competency centres were established across Germany. The core of their work is a seminar programme. It was observed that some GP trainees constantly participate, while others are seldomly seen. The aim of this study was to explore what helps and what hinders constant participation., Methods: GP trainees of the Verbundweiterbildung plus Baden-Württemberg (2008 - 2017), predecessor of the KWBW Verbundweiterbildung plus© program (2017 - present), were included in the study. First, participation in the years 2014 and 2015 was analysed. We recruited the very active as well as the no-show participants for semi-structured telephone interviews. Content analysis was performed by three independent scientists., Results: Participation of n=353 trainees was analysed. N=30 trainees participated in the study (including n=13 no show). The average interview length was 25minutes (13-36minutes). Trainees felt motivated by practice-oriented, varying and learner-oriented subjects. They highlighted the professional and personal interaction and its networking effects. Participants favoured lecturing during working days, topics structuring daily training and supporting every day practice. The seminar moderators' treasure trove of experience and their teaching competencies were regarded as essential. The fact that employers do not regularly grant time away from work to attend the training programme was cited as a major inhibiting factor. Other reasons given for non-attendance included long travel distances, repeat topics or an imbalance between gain of knowledge and social interactions, and finally, a high individual level of work strain, given the dual burden on those trying to combine work and family life and taking on the main responsibility for children., Conclusions: The main enablers (motivators) of participation were practice- and learner-oriented topics and beneficial social interactions. During the seminars, participants experience group membership and the enthusiastic (learning) atmosphere boosts trainees to proceed with their training and follow their career paths in general practice. Continuous participation requires protected time. Competence centres for postgraduate medical education should take these findings into consideration for quality management and programme planning, and, if possible, should initiate and evaluate appropriate countermeasures., (Copyright © 2021. Published by Elsevier GmbH.)

Background: Back pain is one of the most common and costly health disorders in Germany. Rehabilitation measures for back pain often show a lack of long-term effects after rehabilitation treatment. The "Neues Credo" aftercare concept has proven to be promising in increasing the long-term effects. In the current study, it was piloted and evaluated in general practitioners' practices., Methods: A prospective observational study was carried out. Nine orthopedic rehabilitation clinics and N=178 general practitioners were involved in the aftercare. The intervention was evaluated by means of written surveys of 85 rehabilitation patients with chronic back pain at 3 points in time. The outcomes were functional capacity and participation; the secondary outcomes were subjective health and physical activity. The long-term effects were evaluated by analyses of variance with repeated measurements., Results: At the end of the rehabilitation, the main outcome functional capacity shows a significant improvement of small magnitude, all secondary outcomes show significant medium to large effects. During the follow-up period, the participants were able to significantly increase their physical activity. Especially with respect to endurance training and workout. Twelve months after rehabilitation, significant improvements can still be seen in all outcomes. The range of parameters describing effect size are below the usual thresholds for clinically important changes., Conclusion: Rehabilitation aftercare like the program "Neues Credo" shows similar lasting effects when supported by the general practitioner instead of the rehabilitation clinic. The successes decrease somewhat 12 months after the rehabilitation, but we still see significant differences in all outcomes compared to baseline. There is a high satisfaction with the program by rehabilitants and general practitioners. Since general practitioners are the first contact after rehabilitation a transfer of the program into routine care would be promising., Competing Interests: Die Autor/innen geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Objective: Current telemedical services, such as the "docdirekt" project in Baden-Württemberg (BW), are evaluated for optimizing their implementation. Based on the results of this evaluation, strategies for adapting these services for exclusive remote treatment are identified that enable their integration in regular medical care., Methods: In the first part of the study, citizens from BW were individually interviewed on their expectations regarding such a project, and the advantages and barriers in the use of services for exclusive remote treatment. Determinants were explored by means of Mayring's qualitative content analysis. In the second part of the study, these determinants were prioritized by using a quantitative survey of randomly selected citizens from BW., Results: A total of 27 subjects (mean age 51 years, min: 23 years, max: 86 years) participated in the interviews. Most importantly, they found the direct accessibility of healthcare professionals a great advantage. A "24/7" hotline was found to be beneficial, as well as the possibility to get electronic prescriptions or medical sickness certificates. Privacy and a missing physical examination were perceived as barriers. In the questionnaire, the participants (n=217, return 10.9%, mean age: 53 years, min: 19 years, max: 88 years) rated a "direct medical contact" as the most important, followed by the "possibility to get a specialist" and to receive "a first therapy suggestion". In total, n=71 (34.6%) rejected the future use of such a service. The willingness to use the service decreased with increasing age and decreasing digital skills., Conclusion: The study shows that there is an interest in the use of services for exclusive remote treatment. People who intend to use telemedical service prioritize the fast-initial medical assessment and the comfort aspects and, among other things, consider the inclusion of additional services as beneficial. The next step is to incorporate these determinants into the existing telemedical service., Competing Interests: Die Autoren geben keinen Interessenkonflikt an. Die Studie wurde finanziell durch die Kassenärztliche Vereinigung Baden-Württemberg und das Ministerium für Soziales und Integration Baden-Württemberg unterstützt. Die Studie erfolgte weisungsunabhängig., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Background: A growing demand for physicians exists worldwide. Due to political changes, economic incentives and new workplace expectations a trend from single-handed practices to group practices has been noticed in many countries over the last years. In view of this background, our study aimed to identify determinants for success or failure of inter-physician collaboration in order to positively influence future collaboration in anticipation of the important role group practices may play in future health care delivery., Methods: We chose a qualitative study design, using semi-structured phone interviews to collect data from physicians and non-physician consultants with experience in inter-physician collaboration that were analysed using content analysis. Eleven physicians with experience in collaborative working and fourteen non-physician consultants specializing in advice to health care professionals participated., Results: Education in entrepreneurial skills as well as implementation of good practice management in preparation for collaboration are crucial modifiable facilitators for successful inter-physician collaboration. Furthermore, open communication and realistic insight into the mode of acquaintance, moral concept and degree of specialisation of the colleagues involved play major roles for the success of inter-physician collaboration in group practices., Conclusions: There are several underlying themes beyond clinical expertise concerning success or failure of group practices. To influence future collaboration positively, it is important to focus on management and communication skills as well as to address basic understanding of economics.

Background: By comparison with other countries of the European Union Germany is only middle-ranking in terms of telemedicine usage. There is a relevant gap between the legal framework and the actual state of implementation. Healthcare providers play an important role in this implementation process as they are increasingly confronted with the application of telemedical scenarios. Therefore, the aim of this survey was to determine attitudes towards telemedicine of postgraduate trainees in Family Medicine (FM) in Germany., Methods: A cross-sectional survey was conducted between July and October 2016 among postgraduate trainees in FM throughout Germany. The questionnaire covered four topics: attitudes towards telemedicine, barriers for the implementation of telemedicine, assessment of useful telemedical applications and telemedicine scenarios. A descriptive approach was used to analyze the data in order to derive determinants for the implementation of telemedicine., Results: In total, 388 postgraduate trainees from 13 of the 16 federal states in Germany answered the survey. Seventy-eight percent were female. Participants' mean age was 36 years. The majority of participants believed that only a fraction of the already existing technology in telemedicine is being used (70 %). The largest perceived barrier to telemedicine was data safety concerns. More than half of the participants (54 %) believed that telemedicine would change the doctor-patient relationship. 51 % of the participants were interested in training in telemedicine. In this respect, it is important to note that 27 % of the postgraduate trainees said their willingness to practice in rural areas might be facilitated through the availability of telemedical backup for family physicians., Conclusions: Participating trainees in FM in Germany think that the potential for telemedicine is not yet fully exploited. Based on the results of this survey the next steps to be taken for the implementation of telemedicine applications can be addressed., (Copyright © 2020. Published by Elsevier GmbH.)

Introduction: Topics regarding the digitization of the healthcare system are hardly being addressed during the undergraduate training of medical students, even though the promotion of skills in this area has been defined as a learning goal in the German National Competence-Based Learning Objectives for Undergraduate Medical Education (NKLM) since 2015. At the same time, telemedicine as one part of digitization is becoming increasingly important in the public perception as a tool supplementing access to care. Therefore, the aim was to give medical students in the fourth pre-clinical semester a first insight into topics of telemedicine and other aspects of digitization in the healthcare sector as part of a seminar., Methods: On the basis of the existing literature, we developed the content and a didactic concept for the seminar "The doctor-patient relationship in the field of technological developments" in the Medical Sociology course for undergraduate medical students in their second year at the University of Lübeck. Inspired by Kirkpatrick's four-level model, the students were asked for topics they wished to cover regarding the digitization of healthcare and telemedicine at the start and their attitudes towards and experiences with telemedicine at the end of the seminar., Results: A total of 184 students from the fourth pre-clinical semester attended the seminar. The survey response rate was 32%. The topics most frequently requested by students were "Legal Framework", "Electronic Patient Record" and "Tele-consultation". 85% of the students rated the topic "digitization of healthcare" as highly relevant for their future profession. Also 85% of the students wished for easy-to-use telemedicine equipment. A third or more of the students reported considerable uncertainty about their ability to evaluate the benefits of health apps., Conclusions: The contents of the seminar met the students' demands. In the future, topics relating to the digitization of the health system should be increasingly integrated into undergraduate training; also, the students' feeling uncertain about their ability to assess various telemedical applications should be addressed., (Copyright © 2020. Published by Elsevier GmbH.)

Introduction: The primary goal of medical education and training is to develop clinical competencies. Competency-based curricula exist for both medical education which - once the current reform is implemented - will be geared more towards primary care, and specialty training for General Practice. The "Allgemeinarztbarometer" is a German-language instrument to assess primary care competencies during specialty training and has so far been mainly used as a self-assessment tool. The aim of this study was (i) to test the application of the "Allgemeinarztbarometer" in the context of medical education as an external assessment tool (in its "Allgemeinarztbarometer A [ABA]" version) and (ii) to evaluate its basic psychometric properties., Methods: Physicians involved in teaching were asked to assess medical students after a two-week internship in General Practice during their fifth year of study using the ABA (9-item external assessment version). After data processing and displaying basic distributions, we conducted exploratory factor analysis, followed by confirmatory factor analysis. The detected factor structure was then tested for internal consistency., Results: A total of 150 completed questionnaires were included in the analysis. One item showed a high number of missing values (response option "Not assessable"). Exploratory factor analysis indicated a two-factor structure ("Patient-oriented skills" and "General Practice decision-making"). Three items were not unambiguously assignable and hence erased. Confirmatory factor analysis validated the identified factor structure. The two factors showed a Cronbach's α of 0.73 and 0.84 (moderate to very good internal consistency)., Discussion: Our study provides a first analysis of the ABA in the context of medical education. The detected two-dimensional structure shows a high goodness-of-fit when giving up three items still used in this survey. The analysis of missing data showed a high number of "I can't say" answers when assessing the development of strategies against burnout., Conclusions: The ABA (6-item version) seems to be a suitable tool for the external assessment of General Practice competencies in the context of medical education. Further studies are needed to evaluate both the completeness of the assessment and the external assessability of certain items in the context of medical education., (Copyright © 2020. Published by Elsevier GmbH.)