gms | German Medical Science

GMS Journal for Medical Education

Gesellschaft für Medizinische Ausbildung (GMA)

ISSN 2366-5017

Hands-on – general medicine – Circuit-training in the auditorium – a practical equivalent to a lecture

project medicine

GMS Z Med Ausbild 2014;31(3):Doc27

doi: 10.3205/zma000919, urn:nbn:de:0183-zma0009197

This is the English version of the article.
The German version can be found at:

Received: January 27, 2014
Revised: January 27, 2014
Accepted: April 29, 2014
Published: August 15, 2014

© 2014 Blank et al.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( You are free: to Share – to copy, distribute and transmit the work, provided the original author and source are credited.


Introduction: Traditional university teaching formats are of limited use when it comes to conveying the inner workings and specific remit of general medicine in a practical way. Small supervised groups present themselves as a plausible and effective alternative for learning to interact with patients in low prevalence areas.

Description of the project: A frontal lecture was transformed into an interactive seminar-like lecture for 280 students. Short kick-off presentations served as an introduction to rotating circuit stations. Knowledge, skills and professional attitude specific to general and family medicine were intensively trained by 28 small groups in and around the auditorium by means of activating didactic methods. The small groups were supervised by experienced GP’s trained as tutors. During six days, consisting of 3.5 hour sessions per day, working methods, a large variety of common medical conditions, preventive primary care and care for the elderly were amongst the topics addressed.

Results: This new format was successfully implemented and developed with regards to content as well as organisation. Well over 90% of the 274 participating students evaluated tutors’ commitment, coherent delivery of content, learner-oriented atmosphere and practical focus positively. Given the advantages of a small-group learning situation, the somewhat cramped conditions were accepted by 92%.

Discussion: The innovative concept was able to work successfully within the specific framework of patient care in a general and family medicine setting. A creative approach to the lack of space managed to mobilise resources for practical small-group work. Being able to work on specific general practice problems in a small-group setting and immediately reflect upon them was rated positively overall.

Conclusions: Responsibilities and specific working methods in general practice / family medicine can be trained successfully even with large groups of students when limited space is used creatively. In a supervised circuit-training setting, students are able to apply their existing knowledge and skills in a practical way. Further research is needed to assess individual learning success and gains in competence under this novel learning situation.

Keywords: Professional attitude, general practice and family medicine, course, small-group work


Government and society expect university-level teaching in the discipline of general practice / family medicine to adequately convey its occupational profile and have taken fundamental steps towards this goal by setting up academic chairs, the introduction of a mandatory clinical traineeship in general practice and the implementation of general practice / family medicine as an optional subject during the internship year [1]. Students too are increasingly open to the possibility of working as a GP at a later stage [2]. A number of universities have been intensively pursuing the goal of placing more emphasis on practical training contents and general practice / family medicine since the reform of the medical licensing laws in 2002 [3]. Apart from some ambitious individual projects (e.g. in Witten, Berlin, Aachen, Halle), training in general medical practice at German universities generally still consists of traditional style lectures and a block work placement of maximally 2 weeks [4]. This is hardly surprising as the development of a professional and practical day-to-day approach (attitude) and confidence within the daily work in the primary care sector (skills) presents a particular challenge for the didactic process within the framework of a traditional university setting which is heavily reliant on cognitive activities (knowledge) [5]. This becomes more understandable upon closer inspection of the hard to create practical presence of general practice / family medicine within a university setting where nearly all other specialised medical subjects are represented by clinics, experienced doctors and patients from their respective specialist fields. In contrast, the area of general practice operating in an exclusively ambulant and decentralised way can only provide a fragmented description of its specific medical activity, its patients and their typical medical conditions as well as its distinct field of work [3], [6], [7].

Working in small groups, bedside teaching and learning companions have been shown to be effective ways of teaching professional attitude and building confidence [8], [9]. Hardly any of this could be implemented to date at the Technical University of Munich in the area of general practice / family medicine as it involves formats requiring a lot of resources, facilities and time. Apart from a two week work placement, only lectures and seminars employing proven methods for large groups of students have been used.

In view of this dissatisfying starting point, lecturers in the area of general practice / family medicine are faced with the challenge of effectively incorporating the teaching and learning objectives "knowledge", "skills" and "professional attitude" into the didactic and structural framework conditions of the university by utilising existing resources. The development of the seminar-like lecture over a two-year period presents an innovative teaching and learning concept that serves to sustainably implement these criteria.

Project description

The new event has to convey working methods and responsibilities within the specialist field in a targeted and sustained manner. Students should learn to deal with classical diseases as well as non-specific symptoms by building on their current level of knowledge and skills. Initial kick-off presentations can form the basis for a unified starting point in the specialist field. The focal point is on the actual tasks which are worked on in small groups under the supervision of experienced general medical practitioners. How to deal with consultation problems in primary care (particularly with regard to professional attitude) should be taught by example, i.e. exposure to as many experienced general practitioners as possible (see Table 1 [Tab. 1]).

In order to reach a high level of awareness, the format should potentially be taken up by all 280 students of their academic year. The teaching and learning objectives should be communicated in a uniform manner and the didactic elements should be fit for purpose but rich in variety. Rooms and facilities must be suitable for working in small groups. The time-frame must be practical to accommodate all participating teaching physicians (Wednesday afternoons).

With the involvement of experienced educationalists a concept was created, whereby a predefined set of teaching and learning objectives is achieved through working in small rotating groups on six Wednesday afternoons, within a time frame of 3.5 hours. The event consists of six blocks of 3.5 hours each (see Figure 1 [Fig. 1]). A short kick-off presentation (common technical basis) is part of each block and students can prepare for this online prior to the event. Rotating circuit stations of 35-45 minutes are called on in turns by small groups consisting of 10 participants. Take home messages complete each teaching and learning unit. The group results are activated online (see Figure 2 [Fig. 2]).

Shortage of space poses a major problem to the overall concept. 28 rooms are needed for 280 students to facilitate small-group work with a maximum of 10 participants per group. The use of corridors, alcoves, lobbies and meeting rooms in the lecture hall section (canteen, dean's office) is an unconventional but effective solution to this problem.

Organisation of the small groups, i.e. dividing 280 students into 28 small groups and ensuring their rotation presents another challenge. A system of coloured cards, marking of the stations, as well as student assistants and an acoustic signalling system facilitates room allocation and moving between stations.

The selection of content is closely aligned with general practice literature [10], [11]. In order to address frequent consultation issues, individual examples relating to key topics were selected on the basis of case distribution according to Braun.

The development process for the arrangement of individual small groups is part of a multistage system (see Figure 3 [Fig. 3]). Participating students should achieve the best possible learning success on the basis of their knowledge and skills. Each of the groups working in parallel on the relevant topics should assimilate the predefined content in equal measure. In addition, an attractive change in methods attempts to safeguard an optimum learner success within the small groups.

Close coordination between the groups and with university lecturers helped in developing an attractive and methodically variable concept. Discussions, partner work, working on set task sheets, examination of "acting" patients and small presentations are put into practice as typical elements of small group work. Material for online preparation as well as take home messages were created for each topic.

Initial reservations about the difficulty of recruiting and training 28 teaching physicians per event proved to be unwarranted. Many teaching physicians were delighted to be able to participate and donated their time and expertise free of charge. The pre-developed course content and instructional small-group concept were well received, enabling the teaching physicians to focus on their core competency, i.e. teaching a practical approach which can be applied to individual cases. Training of participating GP’s which involved intensive training of individual topics with the relevant committed students and educational experts took place a number of weeks in advance.

The entire event organisation was carried out by experienced students and teaching physicians. Student assistants prepared the circuit stations, divided up the groups, supervised small groups at their circle, managed attendance checks and looked after the tutors.


The format of the learning and teaching event as well as satisfaction levels with the relevant lecturers was evaluated at the end of each block (see Table 2 [Tab. 2]). Of the 280 participants that were announced by the dean's office prior to the event, 274 actually took part (60% women). A near complete evaluation could be achieved in the winter semester as submission of the evaluation was coupled with the attendance check. Evaluations for the summer semester were still submitted by 174 students (63%, of which 64% women) despite one allowed absence and glorious bathing weather on the last day of the course. The vast majority of participants rated the event as largely positive (entirely or to a large degree). This applied to commitment and motivation of lecturers (100% in the winter semester, 100% in the summer semester), positive learning environment (94%, 91%) and comprehensibility and clarity of communicating the course contents (96%, 99%). Working in small groups encouraged critical thinking (84%, 84%) and encouraged questions and active participation (91, 94%). The personal approach of lecturers to individual topics was perceived as interesting (89%, 92%) and connection with later professional practice was conveyed (95%, 94%). At the end of the summer semester 75% concluded that the new format boosted their learning success in contrast with traditional lectures. 92% accepted the disadvantages of the less than ideal space facilities in view of the benefits of small-group work. The event achieved an overall rating of good (2.1, SD 0.9) on a school rating scale of 1 (very good) to 6 (unsatisfactory).


More than 20% of all students will work as general practitioners in future [12]. The remainder will work in close cooperation with GP's in various forms. It is therefore vital for a functioning health care system that future GP's should get acquainted with their field of work and particular working methods in an intensive and practical way during their studies. Adverse conditions can, but don't have to be, an obstacle to the effective teaching of course content. In the case of general practice, problems arise at several levels at once (no patients, facilities and resources on site). Therefore typical teaching formats can impart theoretical content whilst practical content is subject to significant constraints.

The activating format of the seminar-like lecture is able to achieve this goal on several levels. The current knowledge level and skills of students are put to use and supported in their actual case application through the direction and encouragement of supervising medical doctors. Individual efforts are evaluated and personal progress is supported by constructive feedback in small groups. The "Hochschuldidaktik" (often understood as teaching methodology or instructional training for academic teachers - encompasses much more than that, i.e. it focuses on teaching and learning processes in higher education from an academic and vocational perspective) provides valuable feedback on how to best support students in their learning processes [13]. In small groups, students get to know 19 different, experienced and motivated medical doctors who, by personal example, teach the professional approach that is necessary in a primary care setting. This type of learning by example is of vital importance to students [14]. The objective is to make the event as efficient as possible by utilising coordinated content and didactic methods which are developed through the course of several feedback loops (see Figure 3 [Fig. 3]). Specific small-group topics are thus taught in standardised form and independent of the individual medical doctors leading the groups. Teaching physicians can therefore concentrate on their core competency, i.e. professional attitude.

The format could also be spread over 12 semester weeks for the 280 students. This would alleviate the space problem. As the recruitment of sufficient teaching physicians marks the predetermined breaking point of the project, special attention is given to their particular needs. Having to close their practice for just a few days to attend to teaching is important to them. Moreover, they value the opportunity for scholarly exchange between colleagues before and after a course. The event was therefore confined to 3 days per semester.

It takes place in the middle of the semester in order to avoid clashes with examination or other courses. Student adherence is therefore high. Urgent absences can be compensated for by a large group of teaching staff and helpers during the three days. Additionally invited students who are absolving a practical year and doctors undertaking further training provide support for the teaching physicians.

In view of the advantages of the teaching format the lack of space and course places on corridors and in alcoves was rated acceptable by the vast majority of students (92%). The commitment of teaching physicians (100%) as well as the learning environment (91%, 94%) was rated positively. The format promotes critical thinking (84%) and active participation (91%, 94%). The connection with later professional practice was successfully conveyed (95%, 94%). The goal of using motivated general practitioners as a tool for translating the knowledge acquired at university into real-life situations was therefore achieved. Outsiders highlighted the high concentration levels within the groups as well as their activities. Even pre-clinical student assistants managed to gain first impressions of the discipline of general practice / family medicine through their participation.

The organisational effort was immense, but effectively implemented by experienced students and lecturers. Realisation of individual days was a constant challenge due to unforeseen absences. Joint meetings of all participants at the end of the event proved useful. Important amendments could be implemented without delay. Suggested improvements for course contents and instructional design were collated for subsequent events.

The organisation grew progressively more efficient with each event. Activity of the students, dedication of the teachers and the impression that key contents of general practice / family medicine can be conveyed effectively compensated all participants for their efforts. The commitment shown by teaching physicians who independently took on a vast portion of the preparation and organisation in terms of time and content was encouraging.


To convey a real-life understanding of the profession under conditions that match the reality of a family doctor’s field of activity as closely as possible is an ambitious project. Creative utilisation of the available space and didactic potential ensured a fitting portrayal of both the specific remit of general medicine as well as the areas of responsibility of the family doctor. Using over 50 volunteer GP's and 30 dedicated student assistants meant that professional attitude as well as the practical application of knowledge could be taught in small rotating groups which in all likelihood fostered the professional competency of participants as well. Following the successful organisation of the event both in terms of its structure and contents, the focus of research in the coming semester will be on the evaluation of the learning successes and in particular on increasing competencies.

Competing interests

The authors declare that they have no competing interests.


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