gms | German Medical Science

GMS Journal for Medical Education

Gesellschaft für Medizinische Ausbildung (GMA)

ISSN 2366-5017

Recommendations for Undergraduate Training in the Primary Care Sector – Position Paper of the GMA-Primary Care Committee

position paper medicine

  • corresponding author Bert Huenges - Universität Bochum, Abteilung für Allgemeinmedizin, Bochum, Deutschland
  • author Markus Gulich - Universität Ulm, Abteilung Allgemeinmedizin, Ulm, Deutschland
  • author Klaus Böhme - Uniklinik Freiburg, Lehrbereich Allgemeinmedizin, Freiburg, Deutschland
  • author Folkert Fehr - Facharzt für Kinderheilkunde und Jugendmedizin, Sinsheim an der Elzenz, Deutschland
  • author Irmgard Streitlein-Böhme - Universität Freiburg, Medizinische Fakultät, Studiendekanat, Freiburg, Deutschland
  • author Viktor Rüttermann - Drensteinfurt, Deutschland
  • author Erika Baum - Universität Marburg, Abteilung für Allgemeinmedizin, Marburg, Deutschland
  • author Wilhelm-Bernhard Niebling - Uniklinik Freiburg, Lehrbereich Allgemeinmedizin, Freiburg, Deutschland
  • author Herbert Rusche - Universität Bochum, Abteilung für Allgemeinmedizin, Bochum, Deutschland

GMS Z Med Ausbild 2014;31(3):Doc35

doi: 10.3205/zma000927, urn:nbn:de:0183-zma0009279

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

Received: November 27, 2013
Revised: April 24, 2014
Accepted: June 22, 2014
Published: August 15, 2014

© 2014 Huenges 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.


During their studies to become medical professionals, all students are obliged to become familiar with various aspects of primary care. The aim is to provide all students with a high quality training which ensures the best possible cooperation across all sectors of the medical system.

Primary care comprises the primary use of the medical service by an unfiltered set of patients as well as continued patient care – including home-care.

This position paper was developed together with representatives of the German Society of University Teachers of General Practice (GHA), the German Society for Ambulatory General Paediatrics (DGAAP), the German Society of General Practice and Family Medicine (DEGAM) and the German Society for Internal Medicine (DGIM).

It includes recommendations for teaching in the field of primary care in four different types of internships such as preclinical work experience (“Hospitation”), 4-week clinical traineeships of a casual nature (“Famulatur”) and 2-week courses of structured and assessed clinical training (“Blockpraktikum”) as well as a broad-based 4-month elective clinical placement in the final year (known as a practical year, “PJ”).

The recommendations encompass structural and process criteria for internships in different general practices.

In addition, for the first time recommendations for teaching on campus – in the fields of general medicine, paediatrics, numerous cross-sectional areas and other clinical fields, but also for clinical skills training – are set down here.

In this position paper the intention is to demonstrate the possible ways in which more aspects of primary care could be integrated into undergraduate medical training.

Keywords: Primary care sector, medical education


Primary Care in Medical Education

Primary care – a concept originally developed in Britain in the 1920s – is the area of basic provision of medical care in which the primary, (i.e. before any filtering or decision-making process has taken place) comprehensive and individualized care of all health issues takes place.

Primary care includes low-threshold care, including that given by non-medical health professionals as well as within families and local (communal) structures.

Primary care goes beyond general or family medicine, in that it encompasses various models from the points of view of the care issue in question, various professions and their national and resource-specific characteristics [].

In conjunction with undergraduate medical education primary care in Germany relates mainly to the fields of general medicine as well as internal medicine and paediatrics (see the definition of primary care according to § 73 SGB V []), though the representative bodies should ensure a competent general practice-oriented training.

Because it is possible to receive primary medical care in different specialised areas in the German-speaking world, primary care issues should be given consideration not only in the context of medical training in the field of general practice, but also in many other subjects during undergraduate medical training.

This includes in particular:

  • A hermeneutic understanding of the case (simultaneously somatic, psychological and social conditions for illness and health)
  • The general and continuing medical care of a patient in diagnosis and therapy, taking into consideration his home and domestic arrangements.
  • The prioritization and coordination of preventive, therapeutic, rehabilitative and palliative measures in diagnosis, treatment and care
  • The documentation, particularly the consolidation, evaluation and retention of essential treatment data (findings and reports from both inpatient and outpatient care)
  • The integration of non-medical aids and accompanying services in the treatment measures taken in networks together with social and educational authorities and other institutions
  • The patient-centred procedure. This includes effective communication with patients of all ages, including their families and other caregivers in their respective cultural, social and religious context

In German-speaking countries [1], [2] this trend has been observed in recent years, which has recently led to a reinforcement of undergraduate general medical training [] as part of the German Approbation Regulation for doctors [].

Background for this trend include sociodemographic and health economic issues, which necessitate in particular the advancement of general practice newcomers – especially in structurally-weak areas [3].

The German Council of Science and Humanities [4] and the German Medical Council's [5] approach has been to predicate a close relationship between changes in the living environment, population structure, morbidity, progress made in biomedical research and the quality of professional patient care.

Beyond Germany elements of primary patient care are also increasingly being integrated into the training of medical students [6].

But the focus of this position paper is not to secure the next generation of general practitioners [], [7], rather far more to give the doctors of tomorrow a sound general medical training in a health system which is becoming increasingly specialized and to influence not only their ability and readiness to cooperate but also their attitude to primary care [8].

The long term goal is to improve patient care through better knowledge of the specific primary care strategy regarding patients in the low prevalence area together with the various somatic and mental and social problems.

Level of evidence, the state of research

In the absence of studies that one can usefully compare – because of different systems [9] – the recommendations are based on the consensus of the committee members, which reflects the discussion in the professional societies.

For this standards defined by the professional bodies DEGAM [10] and GHA [11] and the State Medical Association of Baden-Württemberg [12] for the field of general medicine in the year 2003 were updated and expanded.

The standards presented here are recommendations.

The empirical base is an inquiry into the teaching situation in German general practice locations [13] from the year 2010. The standards that were taken on were those that had already been put into practice in a majority of the locations [14].

The following effects of (early) integration of primary care medicine in the training of medical students were observed [15], [16]:

Early experiences in the primary care sector enable medical students to become familiar with their chosen profession, contribute towards attaining central core competencies and increase the relevance of learned content. There are also potential benefits for other stakeholders especially teachers and patients and can have an influence on their future career decisions.

Early rotations in the primary care area were a component of innovative curricula that have proven effective in the recruitment of doctors in the primary care sector. However, it is not proven that early experience in itself is sufficient to influence a future career decision.

Structure and Process criteria

Concrete recommendations cover structure criteria (which must be fulfilled ahead of the admission of students) and process criteria (which continuously have to meet the teachers’ needs in the course of their task). These criteria are to be understood as a recommendation any deviation from which in individual cases must be well-founded.

Degree of recommendations:

Recommendations will be made for each section. They will be graded in the following way:

  • "Are" - About this recommendation, there is broad consensus by those carrying out teaching in the primary care sector. Good empirical studies show positive effects
  • "Shall" - standards to be strived towards which have already been implemented in most institutions.
  • "Should" - standards to be strived towards that have not yet been implemented in many institutions. Empirical evidence is largely still pending
  • "Can" - potentially positive effects on outcome are to be expected or are inferable

Recommendations for instruction in teaching practices

Because of different demands on teaching practices according to each stage of training, the requirements below are divided according to general requirements, requirements for teaching practices for practical internships for clinical traineeship practices, for teaching practices in practical courses and for the PJ training.

General requirements for internships in primary care practices


Internships in the primary care area form a broad spectrum of educational content, which is typical for primary care.


The practice characteristics must match the curricular requirements of each course. These are determined by the respective section managers.


In practice, there is adequate space available for students and teachers. This includes a consultation room, in which students may at times talk to and examine patients on their own.


In practice, there is access to practice-relevant medical information (e.g., Internet, reference library, scientific journals) for students


Teaching doctors in primary care are familiar with the medical, organisatorial and economic management of a practice that reflect, in a self-critical way, their own dealings regarding quality management, they keep their competence up to date through regular and intensive training and as such take on tasks related to the teaching as well as training and continuing medical education.


Teaching physicians should demonstrate a willingness to actively contribute to scientific investigations in primary care, such as through participation in health service research projects.

Explanation: Both in terms of a career path in "general medicine" as well as subsequent interprofessional cooperation, there needs to be more emphasis placed on creating a positive perception of the subject during the period of training. This includes efforts such as continuous training in psychosocial skills and a proportionately high profile for the subject, for example in the form of longitudinally-organized programs. The extent to which such measures can also contribute in Germany to changing mind-sets and gaining new recruits for general medicine should be evaluated [17].

Recommendations on internships in the early stages of study


Students should be brought into contact with the primary care sector early on in their studies.

Explanation: The longitudinal, repeated engagement of students in primary care allows training possibilities to be expanded, the interest of the students in primary care to be aroused and a mentoring relationship with a family doctor to be established.

Early patient contact can motivate students both in their studies and their job and so help improve a professional attitude [18], [19], [20].

The recommended course content could include:

  • Building a robust doctor-patient relationship through practical communication skills (e.g. investigating patient history under the conditions of outpatient medicine), characterized by a bio-psycho-social attitude
  • Physical examination methods
  • Introduction to the various stages of diagnosis and interpretation of existing findings and documents
Recommendations for internship practices

Periods of work experience give students in early stages of training the chance to undertake structured internships.

Criteria for internship practices are governed by the curricular context, the content-related needs of the faculty and the educational context.

Recommendation for the requirements of teaching doctors
  • The teaching doctor has at least 2 years’ experience in the ambulatory section after completion of his or her specialist training
  • The teaching doctor is familiar with the medical, organizational and economic issues of out-patient care
  • He / she is able to reflect in a self-critical way, his or her own actions in terms of practice-oriented quality management
  • He / she keeps his / her competence up to date through regular and intensive training

Professional practice communities have at least one doctor who fulfils the above mentioned requirements.

Requirements for the practice
  • In a practice there are suitable rooms in which the teaching can take place. This includes a consultation room, in which students may at times question and examine patients on their own.
Process criteria for internships
  • The training curriculum is adapted according to the prior knowledge and the interests of the students. Focal points should be agreed on in a preliminary discussion between the doctor and student.
  • The organization of the practice allows time for regular case discussions. The time spent on the education of students should be about 1 hour per day.
  • Students should take over certain tasks - in line with their prior knowledge and requirements – but these should be carried out under the close supervision of the teaching doctor. Following completion of the internship, a feedback discussion between doctor and student should take place. An interim appraisal halfway through the allotted time in which the focal points for the remaining internship period can be set down, is desirable.

Casual clinical traineeships in primary care (“Famulatur”)

In the autumn of 2012 in response to the first amendment of the ÄAppO for the GMA, the primary care committee formulated its position on the introduction of a 4-week obligatory medical clerkship in the primary care field. This requires each medical student to pass one of four 4-week periods (called “Famulatur”) in primary care. This placement is not structured by a predesigned curriculum. The practice placement can be chosen by students without the influence of medical faculties.

In general the Committee and the GMA welcome the introduction of this obligatory clerkship in primary care, but point out the significant risks involved, which lie mainly in the practical implementation of the clerkship. In order to keep these risks to a minimum, here are four key demands:

  • Quality criteria for internship placements (known as Famulaturpraxen) to be established
  • Collecting points for recommended Internship placements should be established and made easily accessible to medical students.
  • Structure and implementation of clinical training should be evaluated across locations
  • Scholarships for internships in rural areas which are particularly underressourced should be established.
Recommendations for Casual Internships in Primary Care (“Famulatur”)

Medical internships offer students in the second part of their study the chance to obtain work experience in primary care. The object of a practice internship is to become familiar with all aspects of primary care (see general criteria).

The focal points of the internship are to be adapted according to the level of training the students are at. His or her specific interests should be taken into account.

Students should be able to choose the medical clerkships themselves, though the following structural recommendations should be considered:

  • The training curriculum is to be adapted according to the prior knowledge and the interests of the student. It should be agreed on in a preliminary discussion between the doctor and student.
  • Within the framework of the internship, feedback discussions between doctor and student should take place in which material already covered should be discussed and focal points for the next stage of the internship should be set down.
  • At least three structured feedback discussions are to be recommended, to take place at the beginning, in the middle and at the end of the internship.

The range of recommended internship practices within commuting distance from where the student lives should be made known to the student.

It is advisable to evaluate the clinical training in primary care across the various sites and to make the evaluation results available to the students.

One of the internship agencies [] which is jointly supported by the professional societies (DEGAM, GHA, DGAAP, DGIM) and the Federal Representation of the medical students (BVMD) should also make material available and voice its recommendations regarding content. Further internship agencies are in the process of being established.

It is recommended that the above-mentioned quality criteria should be considered by the internship agencies.

Practical placement courses in primary care („Blockpraktika“)

Block placements are internships in primary care which follow a strict curriculum. Block placements are assessed and the result contributes to the final grade.

General requirements for the implementation of block placements
  • Training objectives and anticipated content are to be made known to students and teaching doctors ahead of the execution of the internship (eg in the form of a logbook).
  • A student's performance on a practical placement course will be ascertained with an appropriate examination format test that reflects the core contents of the placement. In the case that the placement is to be graded by the teaching doctor then he or she should be appropriately prepared for this (the task, the expectations and the evaluation criteria). Alternatively, an examination can be carried out centrally (in the form of an OSCE).
Recommendations for Placements in General Medicine (Blockpraktikum)

The general medicine placement is prescribed by the ÄAppO and the contents are laid out in internal faculty learning objective catalogues.

It comprises at least 2 weeks. The hours involved should amount to between 30 and 36 hours per week.

The general medicine placement is to be completed in general medical or family doctor (internal-specialist) teaching practices that have been accredited by the relevant university.

Contents of these placements should be coordinated with other courses offered by the respective location/institution.

The various locations should between themselves reach an agreement as to the contents of the placement, whilst at the same time paying attention to the position laid out in the Curriculum.

Students should be allowed to choose the practice from a given list for themselves, in which location and focal ponts of the various practices should be communicated to them so that they can make their choice.

Recommendations for Placements in Paediatrics

The paediatrics placement should be expanded to include the possibility to spend part of the time in practices specializing in children and youth.

In paediatric teaching 'blocks' or sections, it is recommended that at least eight hours is spent in general paediatric practices.

Useful content which cannot be done in the paediatrics placement in the clinic setting, includes sensitivity towards and first experiences with:

  • Conversing with children and young people, including caregivers
  • Check-ups and vaccinations
  • Assessment of the physical, social, psychological and intellectual development of children
  • Detection and coordinated treatment of behavioural disorders of children and adolescents
  • Indications, implementation and evaluation of development and psycho-diagnostic tests
  • Investigation of speech, language and speech development
  • Supervision and training of children with chronic illnesses
  • Support and advice on dietrelated health problems
Recommendations for Placements in the Subjects of Internal Medicine, Gynaecology and Surgery

When designing these placements, value should be placed on ensuring that the primary medical and ambulatory care of patients is adequately taken into account.

Thus, the point of intersection with the primary care sector (contacting the GP who will be doing the treatment, discharge management, medical reports) should be addressed in each respective placement.

It is suggested that a check is made at faculty level as to whether or not in order to fulfil the respective teaching goals of this placement, parts of it might be able to be carried out in ambulatory care (i.e. specialist medical practices).

Recommendations for Teaching Practices for Placements (Blockpraktika)
Requirements for teaching doctors:

Teaching doctors for the placement work in the statutory health care system

  • Teaching doctors for the placement are established or salaried specialists for general medicine or internal medicine / primary care or paediatrics with at least one practice based-mandate which may be shared with several people. Practitioners of other disciplines may be entrusted with the implementation of a placement in individual cases, as long as they meet the general requirements and all the training goals of the placement.
  • Teaching doctors for placements have two years of experience in ambulatory care after completion of specialist training.
  • Teaching doctors are to be prepared in an appropriate manner for the placements (i.e. with preparatory seminars, in the framework of regular training sessions or personal briefings) for a period of at least four hours. The object of this instruction are the content and form of the theoretical and practical teaching at each respective location, objectives and organizational frameworks of the placements and familiarization with the feedback, testing and grading of students.

Teaching doctors get a contract with the relevant university in which the local accreditation criteria have been established with which the teaching doctor is obliged to comply. Teaching doctors are to be selected via a suitable accreditation process (introductory event, personal interviews or evidence-based quality characteristics).

The accreditation for teaching practice should be limited in time, and should be controlled at least every 5 years. Relevant criteria for reaccreditation should be student feedback / evaluation results and compliance with prescribed minimum standards for the placement.

The training module is to be appropriately rewarded.

Demands on teaching practices in primary care
  • The teaching practice is of a reasonable size (at least 400 medical cases per quarter).
  • The patient clientele includes an unselected patient population with typical general medical or paediatric issues from different age groups
  • Teaching practices are based on the principle of evidence-based medicine. Practices with strong one-sided orientation (e.g. the predominance of special therapies) and as a consequence a biased patient population are not suitable for the placement.
  • As part of the placement in general medicine, regular house or nursing home visits are required. In particular patients of both sexes who are old and multimorbid are to be cared for.
  • The basic features required by a general medical teaching practice is an ECG at rest and the capability to carry out common laboratory tests (either an own laboratory, a laboratory community, or cooperation with a laboratory). In addition, other equipment or facilities and services which are desirable include sonography, long-term RR and ECG, ergometer, lung function, small surgery / wound care. The condition of these services depends on the training objectives of the respective location.
Process Criteria for the Placement
  • The way in which the practice is organized allows time for regular case discussions.
  • According to their prior knowledge and the substantive requirements of the respective location students may take on tasks that they carry out on their own under the close supervision of the teaching physician.
  • The duties performed are documented in an appropriate manner (e.g., in the form of a logbook) and reported back to the respective specialists in charge.
  • An evaluation by the students through questionnaires and / or feedback discussions as well as feedback by the teaching doctors as to the placement are obligatory.

Practical year

Recommendations for an elective period in General Medicine (PJ)

In the last year of study, students must perform internships in three 4-month periods in internal medicine, surgery and an elective period. The elective period can take place in primary care.

The Practical year in general medical practice should be based on the DEGAM & GHA exemplary logbook on PJ general medicine that is adapted to the site-specific priorities and prior knowledge of students from the general medical training.

The Practical year in general practice should be designed in such a way that doctors of all future disciplines benefit from it.

In seminars that accompany the practical year core medical content as well as general conditions of primary care should be discussed in close consultation with the participants. Alternatively, or in addition to this, E-Learning should be made available to PJ students in the case that practices are far away and therefore hard to reach.

The Practical year in general medicine should be accompanied by competence-based formative examination options in the form of work-based assessments.

The students in their practical year should have a mentor at their disposal who is not the teaching doctor who is training them. The mentoring should take place in the form of personal advice on learning focal points and ideas for the future, quality control and feedback to the department/teaching entity/institute on the progress of the practical year.

Recommendations for the Integration of Practices into the Practical Year (Tertial Paediatrics, Internal Medicine)

As part of the practical year, students should be given the opportunity to rotate from their compulsory subject in Internal medicine, or their elective subject, paediatrics, into a primary care practice for a period of up to 8 weeks.

In other disciplines, an increased focus on outpatient content during training in the practical year would be desirable, since a large part of care takes place within the structure of outpatient care. This may, in the case of internal medicine, include specialized practices.

Recommendations for Teaching Practices for the Practical Year

The practical year is carried out at a teaching practice which is accredited to carry out practical year placements.

The content that can be expected to be covered in the practical year is based on the logbook of the respective faculty. It should take up around 30 to 36 hours per week. In addition, the student is given adequate time for preparation and review.

The following criteria that go beyond the aforementioned criteria can be integrated into the title of a teaching practice in the practical year and qualify for the admission of students for the practical year:

  • Evidence of at least two semesters of teaching in the context of placements (Blockpraktika) or similar forms of practical teaching according to the above mentioned requirements
  • Above average evaluation results from the lessons during the placement
  • Teaching doctors are prepared for their work during a Practical Year (PJ) in an appropriate manner over the course of at least six hours (eg with preparatory seminars or within the framework of regular training sessions, personal instruction). The subject of this instruction is the content and form of teaching at each location, the objectives and organizational framework of the practical year, an introduction to giving feedback to students and the basic process and exam content of the State Examination.
  • Participation in regular advanced training events and meetings at the University amounting to at least four lessons per year.

In addition, the organizational procedure of PJ teaching practice must be adjusted to ensure that the students are able to care for patients both on their own and under supervision regularly and continuously.

This requires:

  • There is a suitable room available in which students can have independent contact with patients.
  • The organizational process of the practice must be adjusted so that at least 60 minutes a day is available for daily case-based discussions. Students in their practical year should be in a position to take on independent tasks, to get feedback about their work as well as to have the opportunity and guidance for self-study.
  • The access to practice-relevant medical sources of information (e.g., Internet, reference library, scientific journals) is obligatory.
  • Content requirements and structural features of the practices follow the training catalogue (Logbook) for the practical year.

It would be desirable to have a delegated power responsible for further training (possibly with participation in joint further training). This would allow for continuity between education and training.

It would also be desirable to have a promotion of the teaching doctor, participation in scientific studies and or work guidelines and membership of a science-oriented professional medical body.

The fulfilment of the above criteria would be contractually regulated and checked during visits in the PJ training practice by representatives of the local teaching college.

The practical year can be adequately reimbursed by the respective locations. An expense allowance or payment in kind for students has to take into account additional costs resulting from the execution of the PJ in the practice (clothes, travel costs and accommodation).

Recommendations for Teaching on Campus

Recommendations for integrating primary care aspects in early undergraduate training.

Aspects of primary care should be taken into account in preclinical teaching.

For this purpose, students should be given the opportunity to sit in on primary care practices during the first stage of their study and to get to know about patient care in family medicine.

Recommendations on Courses in Medical History and Physical Examination as well as Skills Training

Aspects of primary care should be included in the design and implementation of courses in medical history and physical examination.

In so doing the special conditions of medical history taking (focused on consultantbased and exploration of psychosocial environment and experienced medical history) and the physical examination (symptomoriented investigation vs whole body status of healthy patients) in primary care settings are to be taken into account.

Furthermore, it would be desirable to also include communication courses and other skill offers, with regards to the validity and efficiency of various techniques as an aspect of primary care.

Recommendations for Cross-Sectional Areas

For the following cross-sectional areas, the participation or inclusion of aspects of primary care should be aspired to:

  • Medicine of Aging
  • Prevention and health promotion
  • Naturopathy, physical therapy, rehabilitation
  • Health Economics
  • Social Medicine / Occupational Medicine
  • Palliative care
  • Pain Medicine

In so doing internal faculty priorities are to be considered.

Recommendations for Teaching in the Subject "General Medicine"

Instruction in general medicine instruction should span at least two hours per week.

The combination of lectures, seminars and case discussions in small group settings (such as PBL) is desirable. During teaching sessions the contents of different internships can be prepared or debriefings can take place.

Content that is of particular suitability for the teaching of general medicine is summarized in the Core Curriculum of EURACT [21] and is not shown here in detail.

Recommendations for Teaching in the Subject "Paediatrics"

In curricular tuition in paediatrics the core content of primary care should be taken into consideration. This arises as a result of the relevance of, and the frequency with which consultation with primary care doctors who treat children and young people happens.

Teaching in Elective Courses in the Primary Care Sector

Special Aspects of primary care should be offered who show an interest, in the form of elective subjects that zero in on those aspects of primary care.

Recommendations for Teaching in Other Subjects

During the teaching of different clinical subject areas (in particular internal medicine with sub specialisms, surgery, gynaecology, ENT, dermatology, neurology) aspects of outpatient care and aspects of the interfaces with primary care should be addressed.

These include

  • Those diseases of the respective disciplines which are often treated in the outpatient sector
  • Cooperation in the outpatient sector on issues that go beyond the everyday primary care (referrals)
  • The admission of patients and consultation with the general practitioners who have previously treated them in order to gain a complete picture of their medical history
  • The after-care of patients after hospital stays as well as the organization of further care including a discharge management with consideration of the individual situation of the patient and recommendations for further care
  • Crossdisciplinary communication: transfers, admission information, documentation from the inpatient and outpatient care


The following topics will be developed in detail in future position papers. Here the cooperation with other committees of the GMA is useful and desirable:

  • Recommendations for assessment in primary care
  • Recommendations for educational qualification of teachers in the field of primary care
  • Recommendations for academic staff in disciplines that work directly with primary care doctors
  • Recommendations for the appointment of non-university teaching staff in campus events which are relevant to primary care
  • Recommendations for improving the interface between primary care and more specialized patient care
  • Recommendations for research in primary care education


The position paper was accepted by the GMA executive board at 05-22-2014.

Competing interests

The authors declare that they have no competing interests.


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