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Zusammenfassung Hintergrund Hochrechnungen lassen fur Deutschland bis 2020 einen Ruckgang der Hausarzte um ca. 13% erwarten. Dadurch besteht besonders in landlichen Regionen die Gefahr, dass Gebiete nach Bedarfsplanungskriterien medizinisch unterversorgt sein werden. Die vorliegende Untersuchung wurde im Auftrag des bayerischen Staatsministeriums fur Umwelt und Gesundheit durchgefuhrt, um die Zufriedenheit von Arzten in Weiterbildung im Fach Allgemeinmedizin in Bayern mit ihrer jeweiligen Weiterbildungssituation sowie die Bereitschaft zur Niederlassung, vor allem auf dem Land, zu erfragen. Methoden In einem Online-Fragebogen wurden Fragen zum Kontext der Weiterbildung und zur Niederlassungsbereitschaft gestellt. Zusatzlich wurde das „Heidelberger Niederlassungsbarometer“ eingesetzt, ein Fragebogen, welcher Kompetenzen von Arztinnen und Arzten in Weiterbildung in der Selbsteinschatzung abbildet. Einladungen zur Studienteilnahme wurden per E-Mail an Arzte in Weiterbildung im Fach Allgemeinmedizin oder deren Weiterbilder mit Bitte um Weitergabe versandt. Ergebnisse Eingesendet wurden 99 Fragebogen, von denen 95 in die Analyse eingeschlossen werden konnten. 76% der Teilnehmer waren weiblich, 63% in einer Praxis tatig und 37% in einem Weiterbildungsverbund organisiert. Die meisten Teilnehmer (58%) wunschten sich zukunftig eine Tatigkeit in einer Praxis mit mehr als einem Arzt, gefolgt von denen, die als angestellter Arzt (26%) arbeiten mochten. Die Bereitschaft, spater in einer landlichen Region zu praktizieren, war bei den meisten Teilnehmern hoch bis sehr hoch (59%). Eine regelmasige Feedbackgabe wahrend der Weiterbildung erfuhr rund ein Viertel der Teilnehmer. Nahezu jeder zweite wurde strukturiert eingearbeitet. Die Mehrzahl der befragten Arzte in Weiterbildung war mit ihrer bisherigen Weiterbildung zufrieden oder sehr zufrieden (59%). Schlussfolgerungen Grundsatzlich ist die Motivation der Teilnehmer zur Praxistatigkeit, auch in landlichen Regionen, hoch. Obwohl zentrale Elemente einer Weiterbildung wie regelmasige Feedbackgabe und strukturierte Einarbeitung nicht einmal von jedem zweiten erlebt werden, sind die Teilnehmer meist mit ihrer Weiterbildung zufrieden.

Concordance between general practitioners (GPs) and patients is an essential requirement for treatment success and patient satisfaction in general practice. The objectives of this were to estimate the total amount of discordance with respect to reason for encounter (RFE) during consultation in German general practices, and to explore the influence of psychosomatic co-morbidity of the patients in case of discordance.1101 consecutive patients completed a questionnaire, including questions about the RFE and the Patient Health Questionnaire (PHQ). RFEs, as stated by the patients and diagnosed by the GPs were matched according to a predefined index. Factors that may influence the level of discordance between patients' RFE and GPs' RFE were analysed.Amount of concordance was 74.9%, incomplete concordance 11.2%, discordance in different physical RFEs was 9.1%, and discordance when GPs diagnosed psychosomatic illness while patients presented physical complaints was found in 2.5%. The number of RFE (OR 3.03; 95%CI 2.48-3.69; P.001), depression (OR 2.27; 95%CI 1.51-3.41), anxiety (OR 1.78; 95%CI 1.03-3.10) and somatisation syndrome (OR 2.20; 95%CI 1.50-3.22) significantly predicted incomplete concordance and discordance, respectively. The number of RFE was significantly associated with depression (OR 1.32; 95%CI 1.09-1.61) and somatoform syndrome (OR 1.45; 95%CI 1.21-1.74).The considerable amount of discordance and incomplete concordance can partly be explained by the psychosomatic co-morbidity of the patients. If it is seen as a fundamental right of patients to be adequately understood, more efforts are necessary to improve patient centredness. Further studies have to evaluate if improvement of identification of psychosomatic co-morbidity might reduce discordance.

Statistical projections suggest that by 2020 the number of general practitioners (GPs) in Germany will have decreased by about 13 %, which will lead to a risk of medical undersupply, especially in rural areas. This study was conducted on behalf of the Bavarian Ministry of Environment and Health in order to answer the following questions: How satisfied are young Bavarian physicians in GP specialty training with their training situation? To what extent are they willing to start a private practice, in general and, in particular, in rural areas?The study's online questionnaire contained items concerning the context of GP specialty training and the willingness to set up a private practice. In addition, the "Heidelberger Niederlassungsbarometer", a structured questionnaire illustrating self-assessment of competencies of GPs in training, was included in the survey. We asked GP specialty trainees to participate by e-maiI, directly or via their GP trainers.In total, 99 questionnaires were returned, whereof 95 fulfilled the criteria for analysis. In 76 % of the cases participants were female, 63 % working in practice and 37 % in a structured training programme. The majority of participants (58 %) preferred to work in a practice with more than one GP, followed by those preferring to work as a salaried GP (26 %). Their disposition to work in rural areas after having passed their specialty certificate examination was high or very high (59 %). Feedback on a regular basis was given to 29 % of the study participants. Almost every second participant received a structured initial training programme. Most of the participating GP trainees (59%) were satisfied or very satisfied with their training.In general, there is a high level of motivation among study participants to become an independent and self-employed GP, also in rural areas. Despite the fact that not even every second received central training elements like individual feedback and structured initial training, the participants were mostly satisfied with their GP specialty training.

Depression, anxiety disorders, panic disorders, and somatoform disorders are common among patients in primary-care practices (1). Studies from Germany (2, 3) and abroad (4, 5) have shown that patients with greater mental comorbidity utilize the resources of the health-care system more extensively, although the extent of increased utilization also depends on the structure of the health-care system in each country, and on other factors. In an American study, for example, patients who saw their primary-care physicians more than an average of 4.55 times per year were designated “high utilizers” (5). In Germany, contrastingly, the average frequency of contact with the primary-care physician is in the range of 15 to 18 per year (3, 6), although not all contacts are personal: for example, a prescription may be handed out, routine blood work done, or the patient’s blood pressure checked without any direct physician-to-patient contact (7). The higher utilization of health-care services among patients with mental comorbidity is doubly problematic. Inappropriate or unnecessarily repeated diagnostic tests can harm the patient, e.g., by leading to unnecessary surgical procedures (biopsies) or radiation exposure. This risk is greatest among patients with somatoform disorders, for it is these patients who often demand repeated testing to rule out disease (8). Moreover, repeated or misdirected diagnostic evaluation is a misallocation of the limited resources of the health-care system. Early recognition that the patient has a mental or psychosomatic problem would enable him or her to get the appropriate treatment in timely fashion. Referrals from primary-care physicians to specialists can be an especially challenging problem. In principle, targeted referral ought to regulate the delivery of care in such a way that patients get the appropriate diagnostic evaluation and treatment without any excessive consumption of the system’s resources. Rosemann et al. found that most patients (83.2%) are satisfied with the referral process (9), particularly when the initiative for the referral comes from the primary-care physician (10). All of the patients questioned in the latter study had been referred after consultation with the primary-care physician. In everyday practice, however, referrals are often made without any prior direct contact, both because primary-care physicians treat large numbers of patients and have little time to spare and because the patients themselves request such referrals. Primary-care physicians tend to be unhappy about this, either because they think they have not done their job up to a desirable standard, or because they subjectively feel that society’s mandate on the medical profession to coordinate patient care optimally has been subverted by patients, possibly to their own disadvantage. Little attention has been devoted to this problem to date; in particular, there has been no inquiry into the characteristics of patients who request referrals without a prior visit to their primary-care physician. In this study, we investigate the effect of mental comorbidity on utilization of health-care resources in primary care, with special consideration of patients who request referrals without prior physician contact.

Item does not contain fulltext BACKGROUND: Increasing emphasis is being placed on involving patients in decisions concerning their health. This shift towards more patient engagement by health professionals and towards more desire by patients for participation may be partly based on socio-political factors. METHODS: To compare the preferences for shared decision making of patients from eastern and western Germany we analysed five patient samples (n = 2318) (general practice patients and schizophrenia patients from eastern and western Germany). Patients' role preferences for shared decisions were measured using the decision-making subscale of the Autonomy Preference Index. RESULTS: Patients resident in eastern Germany expressed lower preferences for shared decision making than patients in western Germany. This was true after controlling for socio-demographic variables and for patient group. CONCLUSION: The cultural imprint (e.g. western vs. former communist society) seems to have a significant influence on patients' expectations and behaviour in the medical encounter. Health services providers need to be aware that health attitudes within the same health system might vary for historical and cultural reasons. The engagement of patients in medical decisions might not be susceptible to a 'one size fits all' approach; doctors should instead aim to accommodate the individual patient's desire for autonomy. 01 augustus 2012

Background The effect of psychosomatic co-morbidity on resource use for systems with unlimited access remains unclear. The aim of this study was to evaluate the impact on practice visits, referrals and periods of disability in German general practices and to identify predictors of health care utilisation. Methods Cross sectional observational study in 13 practices in Upper Bavaria. Patients were included consecutively and filled in the Patients Health Questionnaire (PHQ). Numbers of practice visits, referrals and periods of disability within the last twelve months and permanent mental and somatic diagnoses were extracted manually by review of the computerised charts. Physicians in Germany are obliged to document repetitive reasons of encounter as permanent diagnoses in terms of ICD-10-codes. These ICD-10-codes are used for legitimisation of reimbursement in German general practices. Results 1005 patients were included (58.6% female). On average, patients had 15.3 (sd 16.3) practice contacts, 3.8 (sd 4.2) referrals and 7.5 (sd 23.1) days of disability per year. The mean number of coded permanent diagnoses was 0.4 (sd 0.7) for mental and 4.0 (sd 4.0) for somatic diagnoses. Patients with mental diagnoses scored higher in depression, anxiety, panic and somatoform disorder scales of PHQ. Frequent practice visits were associated stronger with coded permanent mental diagnoses (OR 20.0; 95%CI 7.5-53.9) than with coded permanent somatic diagnoses (OR 14.4; 95%CI 5.9-35.4). Frequent referrals were associated stronger with somatic diagnoses (OR 4.9; 95%CI 2.0-11.9) than with mental diagnoses (OR 3.6; 95%CI 1.4-9.8). Periods of disability were predicted by mental diagnoses (OR 5.0; 95%CI 1.6-15.8) but not by somatic diagnoses (OR 2.5; 95%CI 0.7-8.1). Conclusions Psychosomatic co-morbidity has a stronger impact on health care utilisation in German general practices with respect to practice visits and periods of disability whereas somatic disorders play a stronger role for referrals. Time constraints in the practices might lead to frequent contacts as too little time is left for patients with mental problems. Therefore, structural changes in the health care reimbursement systems might be necessary. Mental diagnoses might be helpful to identify patients at risk for high health care utilisation. However, the use of routinely coded diagnoses for reimbursement might lead to distorted estimation of resource use.