gms | German Medical Science

"Medical studies prepare [students] well for the examinations, but poorly for the job as a doctor" [1] concluded a poll of the Centre for the Development of Higher Education (Zentrums für Hochschulentwicklung) among approximately 300 medical students in Germany [http://www.che.de/downloads/Medizinstudium20_Auswertung_Befragung_1102.pdf]. The predominant learning culture of graduate medical education is mainly focussed on passing examinations. Central study contents are not sufficiently connected between different medical disciplines; in addition there is an incomplete connection between study contents and the diverse professional demands of a medical doctor [2].

Students normally deal with differential diagnostic considerations during their medical education in the high prevalence context of a university clinic. However, the differential diagnosis of symptoms with a broad underlying aetiology (e.g., vertigo/dizziness) is completely discussed in a single lecture or seminar, but is distributed among different disciplines (for this example ENT, neurology, ophthalmology and internal medicine). Therefore, as a primary care discipline without methodological or organ specificity, general practice is well positioned to give an overview of the complete differential diagnostic spectrum of various clinical pictures and their epidemiological relevance in the low prevalence setting of primary care.

The didactic concept for this seminar was developed in the context of a diploma thesis in health sciences education [3]. This interdisciplinary cooperation helped us to emphasize the integration of elements which shape content and implementation in terms of a new learning style. This includes the involvement of students to organise learning as well as exercises which promote the autonomy of the learner and learning in complex situations or utilisation of different learning places [http://www.neue-lernkultur.de/index.php].

In addition to differential diagnostic competence, we aimed to develop and foster further key competencies by using different moderation techniques, group exercises, case vignettes, simulation patients and models of the Marburg Interdisciplinary Skills Lab (MARIS), complemented by short presentations, discussions and structured feedback(see Table 1 [Tab. 1]).

At the core of the different modules were interdisciplinary clinical pictures derived from the normal routine of primary care. We initially researched literature about common reasons for consultation in primary care [4], [5]. Lecturers of the department of primary care discussed these results among each other and also with prospective seminar participants and made jointly a justified choice (see Table 2 [Tab. 2]).

The seminar was offered for 4^th and 5^th year students and comprised 42 hours of teaching, 3 hours per week, respectively (14 seminar hours included the objective structured clinical examination (OSCE)). Where available for a given topic, the guidelines of the German College of General Practitioners and Family Physicians (Deutschen Gesellschaft für Allgemeinmedizin) formed an important foundation for the design of the different seminar modules.

For the didactic design of the single seminar modules we put a special focus on the diagnostic accuracy of symptoms and signs in regard to the different underlying disease aetiologies of a given clinical picture. Contrary to other clinical specialties, where students are usually presented with very rare diseases which they might -if ever- rarely encounter in their medical career, we primarily concentrated on common aetiologies. Each lesson started with an overview of the results of symptom evaluating studies in primary care for the given topic. Rare diseases were taken into consideration only if they presented as an avertable hazardous condition (e.g., basilaris insult in patients with vertigo as lead symptom).

Indications for further technical procedures, as well as the interpretation of examination results, were integrated with technical examinations normally available in a general practitioner’s (GP) surgery (e.g., laboratory, ECG, stress ECG, pulmonary function testing, and abdominal ultrasound). In addition, we discussed each clinical picture/disease under which condition referral to a specialist was indicated.

We needed approximately 30-35 hours of preparation time for 3 teaching hours (each 45 minutes); this included searching for literature, discussing the didactic outline of the particular seminar unit, preparing presentations and group exercises, and training simulation patients and tutors..While the content-related preparation was done by 2 staff of the department of family medicine (1 GP and 1 GP trainee), the training of simulation patients and tutors was performed by 2 MARIS staff.

Our seminar can be regarded as a pilot project. We wanted to investigate how much effort is necessary to realise such an interactive seminar and how the chosen interactive teaching methods are accepted by the students.

Seventeen 4^th and 5^th year students participated in the seminar. The course was initially advertised for 25 participants and quickly filled. Unprecedented changes in the overall lecture schedule of the university meant that some of the students could not take part.

In the first seminar unit we used fever as a lead symptom to explain different diagnostic strategies that are used explicitly or implicitly by GPs [6], [7], [8]. While most students were familiar with hospital daily routine and thereby accustomed to procedures like the hypothetico-deductive model or clinical decision rules, other, rather typical, primary care approaches needed further explanation (e.g., Bayes’ theorem, cognitive continuum, taking into account the impression of the patient, inductive foraging, use of simple heuristics). During further seminar units we repeatedly pointed to these different approaches and their respective role during the process of differential diagnosis.

For the larger differential diagnostic topics such as chest pain, dyspnoea, abdominal pain, and vertigo/dizziness, we planned 2 sessions for each topic, e.g., 6 teaching hours. We hereby followed a partly standardised teaching outline for the different clinical pictures. A session normally started with a case vignette or a simulation patient who was trained in a role that left room for many potential differential diagnoses. We then used different moderation techniques (e.g., brain storming, mind mapping) to give an overview of potential differential diagnoses. In a next step, the students had to match the different aetiologies with the corresponding disease frequencies in primary care. Here most students overestimated the incidence and prevalence of rare, but often life threatening diseases (e.g., pulmonary embolism as underlying aetiology of chest pain or ileus as aetiology of abdominal pain). Contrarily, students allocated significant lower prevalence to common diseases in primary care (e.g., chest wall syndrome or senile vertigo). Some diseases were not mentioned at all as they were not known to the students (e.g., irritable bowel syndrome).

After a short presentation of results of symptom evaluating studies in primary care in regard to underlying disease prevalence, we normally proceeded with extensive small group work. With the help of simulation patients and different models we simulated either different acute, potentially hazardous conditions, or chronic diseases. Students then rotated in small, tutor-supported groups of 4-5 participants through 3-4 different stations.

Every seminar session was complemented by short lectures, different quiz formats (ECG quiz, ultrasound picture quiz) and short, interactive, small group exercises (e.g., algorithm puzzle: as a final learning success control after one session students had to include the corresponding contents in an empty algorithm). In addition to the seminar material, we offered additional literature as obligate and facultative reading material on an online learning platform “k-Med” (knowledge in medical education) for follow-up learning. Table 3 [Tab. 3] shows an example of the course outline for the two sessions about chest pain.

We decided on a mixed format for the final OSCE: Students’ performance was judged and expressed as a grade; we then provided feedback for students, namely a formative element. Giving feedback is in accordance with the principle of fairness in an evaluation and is useful for the learning effect out of the examination situation.

The OSCE should not only examine selective skills or clinical competencies, but a complete doctor-patient encounter, including history, physical examination, critical judgement of different differential diagnoses, ordering and judgment of further examination results, final diagnosis, and advice for therapy. For this purpose, the authors developed several roles for simulation patients addressing the different clinical pictures taught in the seminar. Patient roles of the seminar were not used a second time. In addition, we developed detailed check lists for each OSCE station. The different roles and check lists were discussed and modified accordingly. We did not pilot the simulation patient roles or check the interrater reliability of the check lists as our department will soon evaluate both of these elements on a larger scale in another research project.

The OSCE occured on the last seminar day. Each of the six stations (chest pain, dyspnoea, abdominal pain, vertigo, knee pain, and back pain) lasted 20 minutes and every student passed through two stations. OSCE stations were staffed by GPs from the Department of Family Medicine at the University of Marburg, Germany who acted as raters.

Having assessed the patient history, students were asked to list the broad spectrum of potential differential diagnoses. For some students, this format of a classical oral examination made it difficult for them to relate to the patient during the subsequent physical examination and the student continued to communicate with the examiner. The role of examiners should be considered when preparing for future OSCEs; the examiner could work as a silent observer through the duration of the examination and only ask for further information at the end of the examination, if needed. In addition to the check list ratings, we also asked the examiners to give a ‘felt’ overall grade; the final grade was calculated in consideration of these two grades. Table 4 [Tab. 4] shows the check list results for the different OSCE stations.

At the end of each seminar unit we conducted a short oral evaluation in regard to content and didactic design. On the following day, the lecturers discussed the feedback provided by the students and changed the teaching material accordingly (formative evaluation). At the end of the last seminar unit we conducted a written summative evaluation using a standardised questionnaire which was developed by the evaluation unit of our university. Here we cite two quotations in regard to the question of which elements of the seminar the participants did or did not like:

“That this seminar finally taught the basics of medicine, not just the rare diseases.”

“Good methodology (simulation patients, group work, moderation cards). Useful division in symptoms.”

Figure 1 [Fig. 1] shows the global results of the summative evaluation.

In summary, both the chosen topics and the way of didactic transfer were received very positively by the students. Towards the end of our course, some seminar participants took the mandatory elective course in general practice parallel to our course and reported how helpful and relevant the topics of our seminar were for their work in family medicine.

The conception of interactive teaching sessions is very time consuming. This relates to both the preparation of single seminar units, including simulation patients and training of tutors, and the preparation of the OSCE.

The predominantly positive feedback of the course participants and the depicted practical relevance of our seminar for the elective in general practice seem to justify the high preparation effort moreso as necessary preparation time will reduce for future courses. In addition, the seminar ‘Differential Diagnosis in primary care’ will become an integral part of a new curriculum in our medical department, which puts a thematic priority on primary care.

The authors declare that they have no competing interests.