Search

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: 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.)

Background: In recent years, the motivation of the new generation of general practitioners to set up their own practice is decreasing. Knowledge of factors that promote and inhibit the process of setting up a practice can enable developing strategies to support this process. The aim of this study was to explore these determinants., Methods: Between April and October 2016, self-employed general practitioners from Baden-Württemberg were invited to participate in a qualitative interview study. Stratification of 553 physicians, who participated in a general practice support program between 2008 and 2011 and set up a practice in 2008 to 2014, was based on the agglomeration in rural areas, the peripheral zones around the agglomeration and the urban agglomerations themselves. The transcripts of the interviews were analyzed by two authors with the content analysis according to Mayring and summarized. In a second step, a consensus version was elaborated., Results: A total of 23 general practitioners were recruited, 57% female and 42 years on average, and mostly working in group practices. The main motivation to set up a practice was the desire to improve the situation in relation to the daily clinical routine. These included a lower duty load and more family-friendly working hours. Relevant supportive factors during setting up a practice were family support, participation in a postgraduate training rotation network program and professional counseling. Inhibiting factors were fears of recourse and indebtedness, a complicated accounting system and a bureaucratic process of admission., Conclusions: On the one hand, the study shows that the many advantages of working as a general practitioner, such as its being family friendly, need to be better communicated to the doctors and their financial concerns alleviated. On the other hand, the need for courses on management of one's practice has also become clear. A standardized and optimized process of setting up a practice with an improved overview and a collegial contact person can facilitate the decision for and implementing the setting up a medical practice as a general practitioner., 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/).)

Objective: In many places in Germany, the need for primary care physicians has been steadily increasing for several years, especially in rural areas. It is hypothesized that physicians are more likely to practice in rural areas if they have received a broad education and vocational training. Differences between general practitioners (GPs) and physicians in general internal medicine (GIM) in the breadth of their vocational training are created by the underlying distinct training schemes. The aim of the analysis was to test whether GPs and GIM physicians differ in their distribution between urban and rural regions of Schleswig-Holstein and whether there are differences in the rate and frequency of performing home visits., Methods: Based on invoicing data of the Association of Statutory Health Insurance Physicians in the federal state of Schleswig-Holstein (Northern Germany) covering the years 2015 up to the third quarter (Q3) of 2018, we analysed differences between GPs and GIM physicians in their regional distribution. Furthermore, we looked at differences between both specialties regarding the application rate and the number of home visits performed and unforeseen physician visits. In addition to bivariate approaches, we also used multivariate regression analysis., Results: Between 2017 (Q4) and 2018 (Q3), 1,378 GPs and 585 GIM physicians provided medical services in Schleswig-Holstein. While 27.5 % of the GPs had practices in rural areas, the share of GIM physicians was 14.5 % (p < 0.001). Home visits were performed by 97.8 % of the GPs and 93.2 % of the GIM physicians (p < 0.001). This difference was even more pronounced in rural areas (99.5 % vs. 94.1 % (p = 0.002)). Significant differences have also been found in the number of billed home visits. GPs made 36 % more home visits than GIM physicians. In rural areas, the difference was 60 %., Conclusion: The analysis revealed significant differences between GPs and GIM physicians regarding the type of region where they work, the application rate and the number of performed home visits. The findings could foster a discussion about how GIM physicians can be better prepared to provide primary care, especially in rural areas., (Copyright © 2020. Published by Elsevier GmbH.)

Objective: The aims of the study were the translation and a first reflection of the psychometric properties of the Aeronautics and Space Administration-Task Load Index (NASA-TLX), a multidimensional instrument to measure workload in general practice., Methods: During April and September 2015, the NASA-TLX was translated and evaluated. For this purpose, a questionnaire composed of the NASA-TLX items and others items related to demographic data, was developed. Postgraduate family medicine trainees and family physicians were then asked to assess patient consultations by applying the questionnaire. The psychometric properties of the NASA-TLX were identified using explorative and confirmatory factor analysis. Reliability was assessed using Cronbach's α., Results: Overall, 16 participants completed 769 surveys after a single patient consultation. The highest average was observed for the item 'mental demand' (mean 6.9 ± 5.4), followed by the item 'effort' (mean 6.6 ± 5.5). Factor analysis revealed a one-factor solution with an explained variance of 56.9 %. The German version of NASA-TLX demonstrated a high internal consistency (Cronbach's α = 0.84). Confirmatory factor analysis showed that there was an acceptable consistency between the expected unidimensional structure and the data., Conclusions: The German version of NASA-TLX provides preliminary indications of psychometric properties and presents an important tool to evaluate family physicians' workload in direct patient contact., (Copyright © 2019. Published by Elsevier GmbH.)

Background: In most western countries a shortage of general practitioners (GP) exists. Newly qualified GPs often prefer to work in teams rather than in single-handed practices. Therefore, new practices offering these kinds of working conditions will be attractive in the future. From a health care point of view, the location planning of new practices will be a crucial aspect. In this work we studied solutions for locating GP practices in a defined administrative district under different objectives., Methods: Using operations research (OR), a research discipline that originated from logistics, different possible locations of GP practices were identified for the considered district. Models were developed under two main basic requirements: that one practice can be reached by as many inhabitants as possible and to cut down the driving time for every district's inhabitant to the next practice location to less than 15 minutes. Input data included the demand (population), driving times and the current GP locations., Results: Three different models were analysed ranging from one single practice solution to five different practices. The whole administrative district can reach the central community "A" in at most 23 minutes by car. Considering a maximum driving time of 15 minutes, locations in four different cities in the district would be sufficient., Conclusion: Operations research methods can be used to determine locations for (new) GP practices. Depending on the concrete problem different models and approaches lead to varying solutions. These results must be discussed with GPs, mayors and patients to find robust locations regarding future developments., Competing Interests: The authors have declared that no competing interests exist.

Background: About 1.6 million rehabilitation applications are submitted to the German pension insurance annually. Physicians working in ambulatory care play an important role in the application process. Studies show that there is too little knowledge about medical rehabilitation in these groups of physicians, the detection of rehabilitation needs and the process of application for rehabilitation. Against this background, a website Information for Doctors on Rehabilitation & Retirement was developed which addresses especially these needs. The aim of the study was to evaluate the website within a practical test., Methods: The practical test was performed with a mixed Methods Approach: 1) Quantitative survey with respect to increased knowledge after using the homepage, 2) assessment of cases with regard to rehabilitation indication and 3) evaluation of the user friendliness of the homepage by participating doctors by means of think-aloud technique., Results: A total of 79 postgraduate General Practice trainees participated. They had high information needs regarding different aspects of rehabilitation, which were partly satisfied by the use of the homepage. The correct assessment of rehabilitation cases improved with the aid of the website for general practitioners with experience with application for rehabilitation only. The homepage was evaluated as clear and helpful, but the texts were judged as too extensive., Conclusion: The homepage can support physicians working in ambulatory care with respect to rehabilitation. Some impulses for optimization of the content have been identified and can help to further increase the usefulness of the website., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Comprehensive outpatient medical care is being increasingly threatened due to the decreasing willingness of physicians to establish their practices in rural areas. Partly, municipalities feel impelled to support doctors setting up their practices with their own resources. The aim of this study was to get the community perspective on the ambulatory care situation and to examine the role and influence of the local authorities., Methods: The mayors (n=411) and district administrators (n=38) in Lower Saxony received a self-developed written questionnaire in September 2015 (comprehensive survey)., Results: The response rate was 72%. Availability of general practitioners was considered as inadequate by 30% of those surveyed and 71% described specialist care as being insufficient. Two-thirds of respondents saw local problems with filling vacant doctors' offices. 42% of mayors and 65% of district administrators said they had already supported outpatient doctors. The most frequent measures carried out so far included financial support, consulting services and the development of cooperation and networks. The majority considered the model of medical care centers being operated under municipal sponsorship to be unsuitable in principle., Conclusions: Local governments prevalently see problems with filling vacant doctors' offices as well as a need for local support. A significant proportion of municipalities has already implemented various support measures. Community participation in the outpatient care with medical care centers under municipal sponsorship is assessed rather critically., Competing Interests: Die Studie wurde finanziell unterstützt durch Fördermittel der AOK Niedersachsen und der Kassenärztlichen Vereinigung Niedersachsen., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Key recommendations for the management of patients with polypharmacy are structured medication counselling (SMC), medication lists and systematic medication reviews., Objective: The aim of this study was to identify determinants (hindering and facilitating factors) for the implementation of the recommendations in general practice., Methods: This study was linked to a tailored intervention aimed at improving the implementation of the recommendations in German general practice. Interviews and focus groups with different healthcare professionals were carried out in the design phase and after delivery of the intervention. The material from both data collections was analysed separately in a content analytical approach resulting in two sets of categories. For this study, the subcategories of both sets were assigned to the Tailoring Interventions for Chronic Diseases (TICD) checklist, a comprehensive framework of determinants of practice., Results: Interviews with 24 general practitioners (GPs), 4 other medical specialists, 1 pharmacist, 3 nurses and 6 medical assistants as well as 2 mixed focus groups with 17 professionals were conducted. We identified 93 determinants: 29 referred to medication counselling, 21 to the use of medication lists, 20 to medications reviews and 23 to all recommendations. The determinants were related to all 7 main domains and to 25 of the 57 subdomains on the TICD checklist including guideline factors, patient factors, individual healthcare professional factors, social, political and legal factors, incentives and resources, and capacity for organizational change., Conclusion: While many interventions to improve polypharmacy focus on the provision of pharmacological knowledge, a much wider range of domains need to be addressed, such as communication skills, patient involvement and practice organization.

Background: In primary care 15% of patient encounters are perceived as challenging by general practitioners (GP). However it is unknown what impact these encounters have regarding job satisfaction. The aim of this study was to evaluate which encounters are perceived as challenging by German GPs and whether they were associated with job satisfaction., Methods: A total of 1538 questionnaires were sent to GPs in the federal state of Schleswig-Holstein, Germany. GPs should rate 14 medical conditions and 8 traits of patients on the perceived challenge using a Likert scale (1: 'not challenging at all' to 10: 'extremely challenging'). Job satisfaction was measured with the Warr-Cook-Wall job satisfaction scale. A linear regression analyses were used to explore potential associations between for the primary outcome variable 'overall job satisfaction'., Results: Total response was 578 (38%). GPs perceived 16% of their patients as challenging. Psychiatric disorders such as somatization disorder (mean = 7.42), schizophrenia (mean = 6.83) and anxiety disorder (mean = 6.57) were ranked as high challenging while diabetes mellitus type 2 (mean = 4.87) and high blood pressure (mean = 3.22) were ranked as a rather low challenging condition. GPs were mostly satisfied with 'colleagues' (mean = 5.80) and mostly dissatisfied with their 'hours of work' (mean = 4.20). The linear regression analysis showed no association with challenging medical conditions and traits of patients but only with different aspects of job satisfaction concerning the outcome variable 'overall job satisfaction'., Conclusions: Especially psychiatric conditions are perceived as challenging the question arises, in what amount psychiatric competences are gained during the postgraduate specialty training in general practice and if GPs with a mandatory rotation in psychiatry perceive these conditions as less challenging. Interestingly this study indicates that challenging encounter in terms of challenging medical conditions and traits of patients do not affect GP's job satisfaction.

Background: In the future, 'delegation' as task shifting from general practitioners (GPs) to non-physicians will be important in primary care. Therefore, the aim of this study was to evaluate the attitudes towards the concept of task shifting and to identify predictors of a positive attitude towards task shifting from the perspective of GPs., Methods: This cross-sectional questionnaire study analysed attitudes towards the concept of task shifting and delegated tasks from the perspective of GPs who were recruited in the German federal state of Schleswig-Holstein. Descriptive statistics and binary regression analyses were computed to identify potential predictors of a positive attitude towards task shifting., Results: Out of 1538 questionnaires distributed, 577 GP questionnaires were returned (response rate: 37.5%). A total of 53.2% of the respondents were male, and 37.3% were female. A positive attitude regarding task shifting was shown by 49% of the participating GPs. The highest level of agreement (95.2%) was found for time savings with task shifting, and a lower agreement (39%) was found regarding the lack of clarity concerning the responsibilities and legal aspects with regards to task shifting. The most frequently delegated tasks were recording electrocardiograms and measuring blood glucose levels. A positive attitude towards task shifting was positively associated with higher job satisfaction and a need for qualified staff., Conclusion: Our sample of GPs for this study was very open-minded towards the concept of task shifting. Germany is just beginning this delegation, but the implementation of task shifting depends on different aspects, such as legal requirements, adequate payment and qualified staff. Finally, there is a need for continuing professional development in primary care teams, especially for non-clinical practice staff.

Background and Objective: The STarT Back stratified primary care approach has demonstrated clinical and cost effectiveness in the UK, and is commonly used by General Practitioners (GPs). However, it remains unknown how this approach could be implemented into the German healthcare system. The aim of this study was therefore to explore the views and perceptions of German GPs in respect to using a stratified primary care for low back pain (LBP)., Methods: A 90-minute think-tank workshop was conducted with 14 male and five female GPs, during which the STarT-Back-Screening-Tool (SBST) and related research evidence was presented. This was followed by two focus groups, based on a semi-structured interview guideline to identify potential implementation barriers and opportunities. Discussions were audiotaped, transcribed and coded using a content analysis approach., Results: For the three deductively developed main themes, 15 subthemes emerged: (1) application of the SBST, with the following subthemes: which health profession should administer it, patients known to the GP practice, the reason for the GP consultation, scoring the tool, the tool format, and the anticipated impact on GP practice; (2) psychologically informed physiotherapy, with subthemes including: provision by a physiotherapist, anticipated impact, the skills of physiotherapists, management of patients with severe psychosocial problems, referral and remuneration; (3) the management of low-risk patients, with subthemes including: concern about the appropriate advising health professional, information and media, length of consultation, and local exercise venues., Conclusions: The attitudes of GPs towards stratified primary care for LBP indicated positive support for pilot-testing in Germany. However, there were mixed reactions to the ability of German physiotherapists to manage high-risk patients and handle their complex clinical needs. GPs also mentioned practical difficulties in providing extended advice to low-risk patients, which nevertheless could be addressed by involvement of specifically trained medical assistants.

Background: Due to the shortage of midwives in Germany, it is not always possible to provide comprehensive basic postnatal care for young families. Therefore, it is quite likely that general practitioners (GP), who serve as the first contact person in all health matters in our health care system, will be increasingly consulted regarding questions on postnatal care in the future. Consequently, the aim of this qualitative study was to explore central competencies for the care of families in the postnatal phase. Methods: Midwives were questioned about their postnatal activities with the help of a semistructured questionnaire. Thereafter, the interviews were evaluated using the Mayring method. Results: Interviews were conducted with 25 midwives with an average age of 45 years. Knowledge about the (patho)physiological processes of the mother and child during the postnatal phase, a supportive basic attitude, and time are important elements in the work with young postnatal families. Additionally, it is important to obtain competences in psychosocial issues. Conclusion: The acquisition of competences for the postnatal phase appears to be useful for GPs. Among other aspects, creation of a good networking structure with other health professions is important. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: A good 30 years ago general medicine fought for the status of a separate specialty against extensive resistance. Characteristic for the previous state of the "lessness syndrome" was, among other things, that there was no separate terminology, no defined territorial boundaries and no academic tradition in the old federal states of the Federal Republic of Germany (FRG). The aim of the present analysis was to present hypotheses for the development of the specialist in general medicine in Germany as an essential step out of the "lessness". Methods: General practitioners from the former German Democratic Republic (GDR) and the FRG were interviewed on the development of the specialist in general medicine using a partially standardized interview guide. The interviews were analyzed deductively and inductively according to Mayring. Results: In total, interviews were conducted with 28 participants. The average age of the participants was 75 years (minimum 50 years, maximum 91 years), 18% were female and 64% originally worked in the FRG. The participants saw, among other things, the blurred boundaries to other fields,which characterized the cooperation with specialists at that time and the lack of acceptance of the independence of the discipline as inhibiting factors in the development of a separate field. An accompanying symptom of this situation was the lack of and slow progress in establishing the discipline at universities. There was an important influence of the general practitioners qualified in the GDR for the introduction of an all-German specialist in general medicine. Conclusion: The specialist status for general medicine has been influenced by the self-image for the discipline in the former GDR. The development in the areas of optimization of further training and in research, which continues to this day, ensures that the field of general medicine can develop with increasing self-confidence. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Copyright of ZFA: Zeitschrift für Allgemeinmedizin is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: In face of the looming shortage of general practitioners, primary healthcare providers and post-graduate training in general practice are increasingly becoming part of the political agenda in Ger- many. In 2009 the program "Verbundweiterbildungplus Baden-Württemberg" (VWB Jost Steinhäuser3 plus BW) was developed by the Competence Center for General Practice in Baden-Wuerttemberg to ensure primary healthcare in the Thomas Ledig1 future by enhancing the attractiveness of general medicine. This paper describes the experiences that have been gathered in developing a Wilhelm Nieblingpost-graduate training-program for physicians undergoing specialist 4 training in general practice. Project description: The Competence Center for General Practice in Baden-Wuerttemberg supports the organization of regional networks Elisabeth Flum1 dedicated to post-graduate medical education. First core element of the VWBplus BW program is a special seminar series for physicians pur- suing post-graduate training. This seminar program is aligned with the Heidelberg, German competency-based curriculum in general medicine and is meant to promote medical expertise and other related competencies, such as Services Research, business and medical practicemanagement and communication skills. Mentoring and advising the physicians regarding professional and per-sonal planning form the second core element. The third core element is seen in the train-the-trainer seminars that address the competencies of the trainers. In order to focus the program's content closely on the needs of the target groups, scientifically based evaluations and research are carried out. Results: Since starting in 2009, 685 physicians have entered the program and 141 have passed the examination to become medical spe-cialists (as of December 2016). In total, 31 networks, 60 hospitals and 211 general practices have participated. The seminar sessions have been rated on average with 1.43 on a six-point Likert scale by the physician trainees (1=extremely satisfied, 6=extremely dissatisfied). Alongside the medical training, these physicians viewed the exchange of information and experiences with other physicians as very positive and important. In 185 seminars lasting 90 minutes each, the seminar program has presently covered 250 out of 320 units in the competencybased curriculum for general medicine. A total of 281 trainers have been trained in 13 train-the-trainer courses and have rated this course on average with 1.36 on a six-point Likert scale. Above all, the trainers emphasized the exchange of information and experiences with other trainers as very positive. In 2013 the DEGAM concept for its Verbundweiterbildung plus program was developed based on that of the VWBplus BW. Since 2008 over 40 articles on the topic of post-graduate medical education have been published. Conclusion: The steadily increasing number of participants over the years demonstrates that the VWBplus BW is relevant for recent medical graduates and contributes to the attractiveness of general practice. The consistently excellent evaluations of the training program and the train-the-trainer course affirm the focus on the needs of the target groups. The post-graduate VWBplus BW program advances structured, competency-based and quality-oriented specialist training and fosters professional sharing between physicians-something that could also be relevant for other fields. The increasing numbers of participating physicians and specialists in general practice in Baden-Württemberg lead to the conclusion that the VWBplus BW program positively influences the number of general practitioners. [ABSTRACT FROM AUTHOR]

Introduction: In different German regions, seminar programs have been conducted for General practice residents. In each region, selection and teaching of learning content is conducted in a different manner. So far, no structured, standardized curriculum has been implemented nationwide We have investigated, if the development of a common 5-year program of learning topics is conceivable between the different university departments of General practice in Germany. Method: The seminar program working group of the DEGAM (German College of General Practitioners and Family Physicians) has conducted an online survey based on information gathered via preliminary telephone conference (n=7; physicians with postgraduate teaching experience) among all German university departments of General Practice and two non-university teaching institutions, identified via the internet. 884 topics were extracted from 14 Seminar programs. The topics were entered in a database, discussed and categorized: Practice management/practice work flow/standardized documentation forms/quality management (n=33 topics), common acute and chronic diseases, including diseasemanagement programs (n=29 topics), communication, neurological, psychological and psychiatric consultations (n=24 topics), common medical problems, including eye, ear, nose, throat, skin and pediatric problems (n=99 Topics) family physicians general approach, including epidemiology, shared decision making, test of time (n=42 Topics). These topics have been rated for priority and desirable number of teaching-units Results: A catalogue of 111 topics was designed, encompassing 160 teaching units. There is a suggestion of wide topics collections plus an add-on catalogue. Conclusion: A proposal for a 5-year-thematic catalogue for postgraduate training of general practice residents in Germany has been developed. This newly developed curriculumhas the potential to improve knowledge and skills that have not been covered during in-house and ambulatory general practice residencies. [ABSTRACT FROM AUTHOR]

Background: Multimorbid patients receiving polypharmacy represent a growing population at high risk for negative health outcomes. Tailoring is an approach of systematic intervention development taking account of previously identified determinants of practice. The aim of this study was to assess the effect of a tailored program to improve the implementation of three important processes of care for this patient group: (a) structured medication counseling including brown bag reviews, (b) the use of medication lists, and (c) structured medication reviews to reduce potentially inappropriate medication.Methods: We conducted a cluster-randomized controlled trial with a follow-up time of 9 months. Participants were general practitioners (GPs) organized in quality circles and participating in a GP-centered care contract of a German health insurance. Patients aged >50 years, suffering from at least 3 chronic diseases, receiving more than 4 drugs, and being at high risk for medication-related events according to the assessment of the treating GP were enrolled. The tailored program consisted of a workshop for GPs and health care assistants, educational materials and reminders for patients, and the elaboration of implementation action plans. The primary outcome was the change in the degree of implementation between baseline and follow-up, measured by a summary score of 10 indicators. The indicators were based on structured surveys with patients and GPs.Results: We analyzed the data of 21 GPs (10 - intervention group, 11 - control group) and 273 patients (130 - intervention group, 143 - control group). The increase in the degree of implementation was 4.2 percentage points (95% confidence interval: -0.3, 8.6) higher in the intervention group compared to the control group (p = 0.1). Two of the 10 indicators were significantly improved in the intervention group: medication counseling (p = 0.017) and brown bag review (p = 0.012). Secondary outcomes showed an effect on patients' self-reported use of medication lists when buying drugs in the pharmacy (p = 0.03).Conclusions: The tailored program may improve implementation of medication counseling and brown bag review whereas the use of medication lists and medication reviews did not improve. No effect of the tailored program on the combined primary outcome could be substantiated. Due to limitations of the study, results have to be interpreted carefully. The factors facilitating and hindering successful implementation will be examined in a comprehensive process evaluation.Trial Registration Number: ISRCTN34664024 , assigned 14/08/2013. [ABSTRACT FROM AUTHOR]

Background: Western countries are facing the challenges of an imminent shortage of physicians, especially general practitioners. As a consequence longer travel times to doctors' practices may arise. This study aimed to investigate the mobility behavior of a rural population in terms of medical consultations. Methods: An exploratory mixed-methods design was conducted in the Waldshut district of the federal state Baden-Württemberg in Germany. Focus groups and a single telephone-interview with representatives, occupationally affiliated with mobility in the district (e.g. representatives of public transport, nursing-services or the District Office Waldshut), were performed in 2016 and analyzed using Mayring's structuring content analysis. A questionnaire based on the collected qualitative data was subsequently distributed to a random sample of 1000 adult inhabitants living in the Waldshut district. Quantitative data were analyzed employing descriptive statistics. Results: Qualitatively, four focus groups and one single telephone-interview with a total of 20 participants were performed. Therein the necessity of reaching a nearby general practitioner and the importance of individual motor traffic was emphasized. Novel mobility modes of ride sharing and telemedicine were controversially discussed as future transport and consultation options, respectively. Quantitatively, 277 questionnaires (27.7%) were valid and included in our analysis. Mean age was 51 years (SD = 18.5) and 58% (n = 160) were female. Irrespective of the mode of transport 60% (n = 166) expected to reach their general practitioner within 15 min. Using the possibility of multiple answers 47% (n = 192) stated to use a car in order to reach their general practitioner, public transport was used by 5% (n = 19). Nearly 80% (n = 220) could imagine sharing a car with well-known persons for consultations. Turning to a general practitioner via telemedicine was imaginable for 32% (n = 91). Conclusions: Individual motor car traffic seems to be an important factor in providing accessibility to rural medical care. As a supplementation, web based ride sharing has economic and structural potential for reaching a doctor's practice. However, familiarity and trustworthiness need to be guaranteed within this flexible transport mode. Furthermore, telemedicine may be a future approach in order to reduce travel time to a doctor's practice. [ABSTRACT FROM AUTHOR]