gms | German Medical Science

Authors list in alphabetical order.

With this position paper, the committee on graduate medical education of the German speaking Society for Medical Education (GMA) would like to point out some of the central questions for the future of graduate medical education in Germany and also support an interdisciplinary discourse. In the light of an international competition for medical young professionals, the reform of the German national guidelines for graduate medical education, changing societal factors and above all, the obligation to provide patients with the best possible health care, we see an urgent need to professionalize graduate medical education in Germany in a sustainable and evidence-based [1] way.

In terms of concrete issues we focus on planning, implementation, financing and continuing improvement of graduate medical education curricula as well as on a national concept for quality assurance. Furthermore, we also consider wider health policies and socioeconomic factors that determine the medical educational context on the national and the European level.

In the following sections we formulate suggestions that are relevant for successfully shaping the reform of graduate medical education in Germany. We indicate routes of action that could help to integrate graduate medical training in a meaningful way into the lifelong medical learning course of undergraduate, graduate and continuing medical education [2].

With this position paper we build on the decisions made during the 115^th national medical assembly, which are relevant for the medical graduate education in Germany and critically discuss those from a medical education perspective [3]. The elements that are being introduced here will be further examined in various research projects so that evidence-based recommendations can be made for decision makers and to also inform the continuing improvement of the national guidelines for graduate medical education. The GMA is the one scientific society within the Association of the Scientific Medical Societies in Germany (AWMF) that has the most extensive competences in the different areas of medical education, including teaching, learning, and assessment. We are convinced that the GMA and the committee on graduate medical education, with an interdisciplinary and interprofessional team of experts and stakeholders, is especially equipped to provide recommendations and suggestions for improvements for graduate medical education and training in Germany, working at the nexus of clinical practice, health policy and educational research.

A fundamental task consists of the development and the definition of adequate learning goals for graduate medical training, which can be assessed and are internationally comparable. These goals need to be defined as single milestones that lead to the final board examinations as well as overarching goals for the whole period of graduate medical training.

Apart from specialty specific competences there is also a need for defining competences that relate to social, communicative, ethical, economic and health system related aspects [4]. Interdisciplinary and interprofessional approaches are necessary to achieve this goal.

Learning goals should be formulated in a way, so that they adequately reflect the developmental learning phase and experience of the graduate medical trainee, support lifelong learning and allow for a modular structure of graduate medical education. This would lead to a form of graduate medical education that is flexible, individualized, and could be completed in part-time and across more than one institution. Some aspects of this have been implemented already for primary care graduate training. A two-step blueprint structure for all graduate medical curricula, which includes a basic graduate training period, that would have to be provided by all licensed institutions, and a modularized and individual continuation of the graduate medical training should be discussed.

In the line of existing competency based models like the CanMEDS catalogue [5] from Canada or other role-based curricula (Tomorrow’s Doctors [6], [7], [8], Swiss Catalogue of Learning Objectives for Undergraduate Medical Training [9]), a National Competency-Based Learning Objective Catalogue for Graduate Medical Training (NKLWM) needs to be developed, which builds on the currently emerging framework of the National Competency-Based Learning Objective Catalogue for Medicine (NKLM) [10]. Such a catalogue should serve as a framework for developing specific graduate medical training curricula within the different specialties. Therefore an intense collaborative effort of the State Chambers of Physicians, the German medical societies and professional organizations together with their European and international partners would be the way forward.

The Entrustable Professional Activities (EPAs) [11] represent a potential educational system to develop such a NKLWM-framework for graduate medical education. EPAs are defined elements of health professional activities, which can be delegated to a graduate medical trainee without direct supervision (e.g. running the morning rounds). Therefore EPAs can be used as didactic elements that bridge the theory of competency-based graduate training and everyday clinical work.

In order to provide a systematic and evidence-based graduate medical education, we need national structures that support an efficient implementation and a national standardized evaluation.

Existing evaluations of graduate medical education need to be extended through continuing formative as well as specialty and institution specific assessment components.

Since the current Graduate Medical Training Requirements (Weiterbildungsordnung) are being used for both objectives for health care delivery and as a basis for billing of medical services, we insist that competency objectives and remuneration catalogues clearly be separated. The German Medical Association (BÄK) has developed constructive propositions to reform those financing mechanisms [12]. Learning objectives for graduate medical education must not primarily be defined on the basis of monetary factors [13].

Graduate medical education alliances provide an opportunity to identify and take advantage of educational synergies. Therefore medical specialties should form alliances that include all forms of health delivery sectors, particularly private practices as well as hospital-based health services, but also the National Association of Statutory Health Insurance Physicians (KBV). Such alliances would open the window for cross-institutional and intersectoral rotations during graduate medical training.

We need clear and comprehensible criteria for what kind of learning objectives a graduate medical trainee can complete at a corresponding teaching institution. These criteria should be transparent and publicly accessible, so that the individual process of choosing an adequate training institution for each phase of the graduate medical training period is efficient and effective, according to what the personal preferences and interests are.

The individual graduate medical education curricula must meet the standards of educational quality and include continuing teaching sessions within each institution, which need to be specialty specific and practice-oriented.

Ideally, the implemented evaluation processes should be designed as assessment portfolios [14]. Individual portfolios are a central instrument of graduate medical education and use both specialty specific requirements and institution specific resources as well as individual progress of the medical trainee as an orientation.

Furthermore the portfolios serve as an orientation for the medical trainee and also for the respective program director. Within the portfolio all initially defined learning objectives are being documented and reflected. It can be used as a guideline for the different phases of the graduate medical training period as well as for structured and high-quality feedback sessions. Finally, it can also be used for formative and summative assessment formats.

The existing use of personal logbooks, where graduate medical trainees document (independently) executed procedures and learning objectives as defined by the Graduate Medical Training Requirements (Weiterbildungsordnung) needs to be further developed and improved as part of the portfolio. It is thus necessary to define specialty specific competencies as well as general competencies with adequate competence levels.

As a general note, the value of such logbooks has not been evaluated properly in Germany so far, and the duration of its implementation varies between the German states. Therefore it needs to be investigated whether and how it actually supports achieving the relevant learning objectives of graduate medical trainees.

The logbook as part of the portfolio should help the graduate medical trainee to document his or her personal and professional development and allows the program director to critically reflect the progress of the trainee. Before completion of each phase of graduate medical training the program director and the medical trainee should informally and confidentially discuss the progress made. This should help to foster strengths as well as to identify weaknesses or deficits and to plan educational interventions accordingly so that the training can be continued in a constructive way. Completion of the logbook (as part of the portfolio) should be kept as a prerequisite for issuing the final graduate medical education certificate and giving clearance for registering for the specialist examination with the respective State Chamber of Physicians.

There is also an urgent need for effective mentoring programs that support the personal progress of graduate medical trainees. Each trainee should be assigned to a mentor as long as he or she works at a teaching institution. The main task of the mentor should be to support the graduate medical trainee in every aspect of his or her professional development. Especially in the beginning of graduate medical training they should provide practical advice and help with learning the basic work flows as needed. Informal and implicit communication or work flows might be difficult to be recognized for a new first-year resident, and a mentor can help to understand those while fostering the professional self-actualization of the graduate medical trainee.

In order to provide this kind of assistance, mentors need to be qualified as both specialists within their respective area of work and as clinical teachers (educational qualifications need to be incorporated into institutional personnel development plans). The mentoring competence should continually be improved through continuing medical education interventions.

The role of a mentor must be firmly established as an inherent part of graduate medical education within regular working hours, must be recognized as part of the work of a teaching hospital and be mandatory for the role of a graduate medical educator.

One mentor can have several mentees, however each mentee should have one mentor. A mentor/mentee ratio of 1:1 would be ideal.

Successful mentorship should be regarded as a qualifying criterion for requesting the right to provide graduate medical education. As part of a yearly evaluation mentors and mentees evaluate each other (360°-evaluation).

All mentioned aspects should be formulated and described in a separate graduate medical education contract. These include concrete learning objectives, mentoring, clinical rotation plans and times and potential research or international leaves.

Graduate medical trainees must have the possibility to legally claim their right to adequate graduate medical education from program directors.

In order to assure the quality of graduate medical education on a national level, we need to establish a transparent and nationally standardized quality assurance procedure. Therefore the State Chambers of Physicians together with the Federal Chamber of Physician should found a single national quality assurance institution. This institution should be headed by a qualified physician, organized as a national graduate medical education register with capacities to evaluate structure, process, outputs, outcome and impact of graduate medical education in Germany and to provide guidelines for implementing graduate medical training programs as objectives.

Coordination of all involved organizations and institutions, development of curricula, competency-based catalogues and learning objectives, consequent documentation of national statistics on drop-out rates, residency changes, national and international migration of graduate medical trainees, standard setting for curricular content, annual evaluation of graduate medical education in Germany (also targeted evaluations for difficult cases if needed) and serving as a reference institution for graduate medical education quality would be amongst the concrete tasks of such an institution.

Furthermore it would need to initiate quality assurance programs, audits, peer-reviews [15] and to foster graduate medical education research in both national and international contexts.

State Chambers of Physicians might have to adapt their registration policies and expand their cooperation with the Federal Chamber of Physician with regard to effectively sharing relevant data.

At present there is no clearly defined requirement for didactic qualifications of residency program directors. If quality assurance is supposed to be effective all involved stakeholders need to acquire such didactic qualifications.

Structured pedagogical and didactic trainings, supervision and intervision opportunities and possibilities for further development should be offered nationally and should also be defined as service objectives of teaching hospitals.

Consequently the above-mentioned new institution of the State and Federal Chambers of Physicians should provide an adequate blueprint framework for teaching hospitals, residency program directors and their licensing requirements. It should also hold a coordinating capacity for providing specific didactic and pedagogical training courses. Finally, this institution should have ways of suggesting specific sanctions through the different State Chambers of Physicians.

Thus, at the institutional level of graduate medical training providers, there should be a continuing internal quality assurance program as well as external audits or peer-reviews. Again, a national coordination is fundamental.

Another central aspect is the regulation of the specialist exam. Since this exam represents the final step of the whole graduate medical training period, after completion of the minimal graduate training time and successful acquisition of the required competences and skills, fundamental reforms need to be initiated.

The successful completion of the specialty specific EPAs needs to be assessed through adequate and predetermined formats. The detailed elements of this assessment could be documented in the portfolio.

Based on the acquired EPAs the specialist exam should adequately assess all predefined competences of a specialist, before the respective State Chamber of Physicians issues the specialist license. The formative elements of this assessment, which have been collected throughout the whole residency, should be complemented with a summative assessment at the end of the residency. The predefined competences to be tested should be in accordance with European standards [http://www.uems.net]. The summative assessment should reflect theoretical and practical knowledge of the particular specialty in a case-based manner.

Throughout the residency there should be a complementary annual formative assessment. This mandatory assessment could be online-based and the time-point of taking the exam could be self-determined during the respective year. It should serve as self-control of learning progress and support deeper understanding of the theoretical subject matter as well as adaption of individual learning strategies.

Graduate medical education is closely intertwined with the broader health policy context. We need structures that recognize quality assurance of graduate medical education as a distinct health care system output and service. This will not be possible without targeted mobilization of financial resources that would provide residency program directors with more planning security than is now the case.

Options for mobilizing such resources include a residency-specific increase of relative weights of Diagnosis-related Groups (DRGs), increase of the statewide base rates or an increase of rates within the AOP-contract for outpatient operations.

We would like to emphasize the concept of a residency specific block grant, which provides teaching hospitals with funding according to the number of graduate medical trainees actually enrolled in the respective programs.

A fundamental goal for clinical graduate medical education must be the separation of research activities and graduate medical training, especially in the context of academic teaching hospitals. Furthermore, graduate medical education must be recognized as a service of and for the German health care system.

Graduate medical education cannot simply be a side effect of clinical work, since it shapes the future and competitiveness of the German health care system in several fundamental ways. It is in the very interest of all patients to have highly qualified physicians who provide their health care. They also reduce unnecessary costs with evidence-based use of limited resources. Professional codes of physicians need to be adapted accordingly.

Furthermore, the greatest possible personal independence of residents in training from their respective program directors, as well as a continuing documentation of the quality assurance of residency programs must be an overarching goal.

In order to generate adequate action momentum, the freedom of choosing a residency program needs to be maintained. We are not in favor of an institutionalized distribution system of first-year residents as used in some other European countries.

The license to offer graduate medical education programs should be withdrawn if the residency program or the residency director is not meeting (anymore) the required professional or personal standards.

The current reformation of graduate medical education needs to pave the way for a nationally and internationally comparable, competitive, attractive and recognized residency training in Germany. The goal is to combine medical excellence with an emphasis on ethical responsibility, patient-centeredness and patient-safety.

Furthermore it is of utmost importance to allow for a better work-life balance, including personal family and career plans, in the light of changing societal and demographic determinants. Thus it needs to be considered how lengthy residencies potentially counteract personal family and careers plans, and ultimately have a negative impact on the attractiveness of the medical profession.

Finally, graduate medical trainees need to be represented in all relevant decision making bodies (elected representatives from teaching hospitals on a national and international level) and contribute their perspective to ongoing reform processes. A strong self-regulation of medical professions is essential for the future of the health care system.

With this position paper the committee on graduate medical education of the Society for Medical Education (GMA) discusses central challenges of graduate medical education in Germany. There is a lack of scientific data on the different components of graduate medical education (defining competences, curricula, implementation and quality assurance) in Germany. We suggest closing this information gap with critical studies so that an evidence-based and internationally competitive graduate medical education can be provided in Germany.

The position paper was accepted by the GMA executive board at 01-25-2013.

The authors declare that they have no competing interests.