The "general practice class"--an eligible compulsory course in undergraduate medical education: didactical structure, teaching targets and implementation.

Undergraduate medical education in the field of general practice currently faces two considerable challenges: enhancing the attractiveness of general practice for all students and contributing to the necessary future rural physician workforce in primary care. Thus, we introduce a curriculum-based concept called the "General Practice Class" (Klasse Allgemeinmedizin) as an elective compulsory course to be taken during preclinical study. The aim of this concept is to strengthen the program focus on primary care in rural areas for interested students at an early stage.Since October 2011, the "General Practice Class" in Halle-Wittenberg offers learning experiences in regard to GP professional culture and a practice-oriented learning environment for 10% (n=20) of the freshman students. Each participating student is assigned to an individual GP mentor, who acts as a "professional example" and accompanies the student during the entire course of study. The concept of the "General Practice Class" is considered to be an innovative project due to the close connection between practical experience, problem-oriented skills training, early patient contact, and the accompanying face-to-face mentorship, starting from the beginning of preclinical study.

Introduction

Due to the expectations of policy makers and society, undergraduate education in the field of general practice is confronted by two major challenges: all medical students are to acquire the necessary knowledge about the functions and practice of the primary care specialty in such a way that the attractiveness of the field for the upcoming generations of physicians is increased overall. Second, a proportion of medical students is to be recruited to pursue a career in rural general practice [http://www.svr-gesundheit.de/index.php?id=14].

The 2002 amendment of the German medical licensing regulations for physicians, the ÄAppO, also assigned more weight to general practice and the practical content in the medical degree program [1]. The ongoing, practice-oriented development of undergraduate medical curriculum, not just in the area of general practice, is being spurred on by many curricular projects. In respect to the knowledge and skills for the ambulant care sector, particularly significant developments worthy of emphasis are integrated “skills labs” using standardized patients [2], (small-group) teaching with patients in real medical situations [3], and the compulsory clerkship “block practicum” in general practice [4]. However, despite the inclusion of general practice in the instruction of interdisciplinary subjects (Querschnittsfächer) [5], the imparting of general practice content and methods over the course of the medical curriculum is focused on large lectures and clerkships, in contrast to clinical subjects regarding examination techniques, organs or etiologies. As a result, it is more difficult to attract students to general practice, especially in the first years of study, than it is to the specialized subjects. A “curricular longitudinal plan” for improved integration of preclinical with clinical studies in terms of instruction and (in)direct exposure to general practice is also desirable, as is the enhancement of interrelated didactic elements between academic teaching and the working reality of the medical professional operating outside of the hospital setting [6], [7].

Developing an occupational understanding of primary care based on experience and building confidence through medical skills is a long and dynamic process that cannot be “checked off” according to a curriculum. Within the chronologically segmented curricular requirements of the regular course of study (e.g. interdisciplinary subjects, clerkships), it appears to be neither advisable nor realistic to convey a fully developed professional concept to prospective primary care physicians, and to also spark enthusiasm for the occupation of the rural doctor [8]. The aim of promoting the development of a professional identity differentiates the project in Halle from model degree programs, such as those in Witten/Herdecke, Berlin or Aachen. In model degree programs, extensive modification to the medical curriculum is undertaken through change in the sequence of course content (organ-centered learning) and/or a more intensive connection between theory and practice (problem-oriented learning, bedside teaching, general practitioner “adoption” programs); the model course of study in Witten-Herdecke is mentioned here as an example [9], [http://www.thieme.de/viamedici/medizinstudium/modellstudium/infos-modellstudiengang.html]. In contrast, our concept supplements existing structures with an “add-on” elective compulsory course and can, as such, be tailored to a specific target group without forcing faculty to make large changes to the curricular concept. We ascribe a special influence to the imparting of a hands-on understanding of a profession over an extended period of time through mentors within the scope of an elective required course [10], [11]. Students learn to deal with specific issues concerning general practice through instruction, advising, and guidance (expert culture). This allows them to grow into their own self-concept as general practitioner (professional individuation). Through constant sharing and exchange among the entire class of students, as well as with the assigned mentor, students are able to acquire an increasing confidence in terms of taking action and forming judgments.

Despite the reform of the ÄAppO and national support for continuing education, the interest shown by students and young doctors in pursuing further training in the field of general practice has been decreasing for decades, endangering above all the care available to populations in rural and economically underdeveloped areas. Although when surveyed, up to 30% of medical students indicate general practice as a possible area for further specialized training, the distribution of statutory health insurance physicians regarding primary and specialized care shows that developments have been to the detriment of primary care [12], pg. 49, [13], pg. 24. As a result of demographic changes and the shifting of the morbidity spectrum, increasingly more chronically and multiply diseased patients needing continual care in the vicinity of where they live are falling upon fewer “rural physicians”. To create an attractive image of general practice, it must be demonstrated that the heavy routine pressure and complex demands for therapy and long-term patient management, as well as the risks of running a private practice, can be rewarded through specific freedoms and incentives and that they can also be mastered through broad educational experience and further training opportunities.

For the professional goal of becoming a rural primary care physician, Brooks et al. [14] recommends, as a conclusion drawn from a meta-review, offering systematic preparation for the challenges of rural primary care with contact to practices and patients during undergraduate medical education. Studies performed in the USA, Canada and Australia were able to show that interest in rural medicine can be increased, for instance through the completion of a practicum in a rural area [15]. Likewise, early skills training (in the second to fourth semester) correlates positively with a subsequent begin of specialized training in general practice [16]. A convincing presentation, both personally and professionally, of general practice and the opportunity to experience it directly during the undergraduate medical course of study significantly contribute to the motivation behind a later aspiration to pursue this particular specialty and provide a role model for cultivating professional identity [7], [17].

Description of the General Practice Class Project

Since the winter semester 2011-12, the Department of General Practice at the Martin-Luther University Halle-Wittenberg has offered the General Practice Class as a Wahlpflichtfach (elective required course) in accordance with the ÄAppO for a total of 1 contact hour per week per semester. The description of the project’s background and national and international model projects focusing on the shortage of rural physicians has been extensively profiled in the journal Zeitschrift für Allgemeinmedizin [18]. Using a selection process (for more detail, see [18]), 20 students per academic year are admitted to the General Practice Class.

Teaching objectives

The overarching teaching objectives and content of the General Practice Class are oriented toward the European WONCA definition from 2002 of the core competencies of the general practitioner [http://www.woncaeurope.org/sites/default/files/documents/Definition%202nd%20ed%202005.pdf] and the Basel Consensus Statement on communicative and social competencies in medical education [19]:

Early, guided and supervised patient contact in rural primary care practices,

Comprehension and acquisition of complex skills for the responsibilities, working procedures, and methods of decision-making in primary care,

Knowledge, skills, and reflections on experiences with conducting patient-oriented consultations in the general practice setting.

These objectives are not only supposed to contribute to the acquisition of a professional attitude (habitus), but also to the formation of a long-term personal professional view of the general practitioner possible. Learning in an assigned group of students promotes cooperative behavior already during undergraduate study. Group mentoring is planned for six years and can be continued past that in the final clinical year or the regional association for continuing education. As a result, professional options and possibilities which can be planned for in advance become possible for the participants.

Theoretical knowledge is conveyed by an interdisciplinary team comprised of two practicing primary care physicians and a specialist in speech science. As mentors, 20 rural doctors were recruited as experienced practitioners to work together with a mentee for two days per semester over the course of the entire degree program. Through exposure in the mentoring doctors’ practices, students have contact with patients and their families early on and learn the particular work methods of a primary care physician operating outside an urban center. The mentors are prepared for their role in this project in special training sessions, and before being accepted into the mentor program, they are inspected and certified as teaching practices.

As in the preclinical study phase, the intention is to continue the General Practice Class as an elective required course with 1 contact hour per week per semester also during the clinical part of the medical education. The students will continue to visit the teaching practice they have been assigned to regularly and, based on the logbook for the days spent there, speak with their mentors about the short and long-term therapy episodes of (shared) patients, any upcoming treatment measures and their effects on patient lifestyle. In this way, the primary care physician can be observed in the context of long-term care and students can learn hands-on and step by step the functions, responsibilities and approaches of the general practitioner, along with the typical consulting scenarios they face. Prior to graduation, students acquire increasing self-confidence and a better ability to form judgments regarding their own practical expertise and skills (decision-making and responsibility as general practitioner). Students increasingly become agents rather than mere recipients and have the chance to test their own abilities under the supervision of a mentor.

Curricular Concept for Preclinical Study

The General Practice Class consists of four parts which supplement each other: three 90-minute seminars per semester (Communication Training, Skills Training, and Case Reflections) and two days each semester spent on-site at a doctor’s practice with logbook assignments (see attachment ).

The procedures and organization of a private practice are explained in detail during Skills Training. In addition, the students learn from the first semester on about simple examination techniques (e.g. measuring blood pressure) and technical skills (e.g. determining blood sugar), which they are then able to apply much earlier than the students following the regular course of study. Already during the first days spent in the mentoring practice, students find themselves in a position to step out of the passive role of the learner and to work actively with and for patients.

During Communication Training, important skills regarding building, improving and maintaining the doctor-patient relationship are conveyed. This seminar focuses on active exercises followed by a reflective phase, which is bolstered primarily by feedback in the form of nonviolent communication [20]. Precisely the latter has been missed by students as an orientation tool in communication training, as shown by the qualitative study performed by Büchtemann [21]. The students learn to better recognize their own communicative behavior and can more consciously deal with different kinds of communication techniques during doctor-patient consultations. The sequence of the seminar blocks and the holding of each seminar session follow the speech science and andragogic methods (meaning methods of life-long learning and adult education) regarding seminar planning and conduction [22], [23], [24].

The documented, long-term following of a chronically ill patient at the mentor’s practice forms the basis for the General Practice Case Reflections. Here, the students learn to understand individual medical histories and develop a heightened awareness of the significance of the patient’s social environment and biography for the case histories. In doing this, the various possible interpretations of a symptom are discussed in particular [25]. In the seminar, the observed cases are evaluated within the context of hermeneutic case understanding, psychosomatic primary care, and the discoveries made in the Balint groups concerning the doctor-patient relationship.

Already during the preclinical study, there is a close combination of theory and practice in the General Practice Class in such a way that is at present predominantly found in the clinical phase of the medical curriculum or in model degree program.

Evaluation

The process and final evaluation is performed with the goal of ongoing improvement to the content and quality, as well as assuring that the intended audience is reached. To accomplish this, the quality of the project is analyzed in detail in terms of structure, process and results in a total of three partial studies:

Testing of the curriculum under educational and practical conditions (formative evaluation in a semi-experimental longitudinal design using a modified HILVE-II questionnaire) [26].

Documentation of the long-term effects of the curricular project and validation of its effects (summative evaluation using a modified BEvaKomp questionnaire) [27].

Biographical and professional analysis of the (sustainable) formation of an identity as a primary care physician (meta-evaluation of individual and collective professionalization using biographic interviews of all 20 participants in the General Practice Class for the academic year 2011 [28].

Assessment on these three levels is currently underway, either through the evaluation of the questionnaires or the conduction and recording of the interviews. The biographical analyses are being carried out within the scope of a dissertation project in the Department of General Practice.

Discussion

The elective required course, General Practice Class, offers the field of primary care an attractive option for bridging the gap between teaching theory, skills training, and promoting practical occupational skills early on in the preclinical phase of undergraduate medical education. Particularly in respect to the development of social and communication skills, the relevant requirements of the GMA, along with student expectations, are taken into consideration [19], [21]. Approaches for encouraging young (primary care) physicians in rural areas through individualized or small group-oriented projects has already been positively assessed internationally; however, in terms of medical education in Germany, these approaches have yet to be analyzed [15], [16], [17], [29]. The goal of this project is not only to recruit students to pursue a career in rural general practice, but also to try out individual instructional modules (such as Communication Training, early patient contact through on-site presence at a medical practice, etc.) for inclusion in the regular preclinical medical education for all students at the Martin-Luther University in Halle. To efficiently convey technical information, as well as social and communication skills, a curricular concept was developed that makes continual and shared learning possible [19]. The General Practice Class provides potentially “ideal” conditions for this through extensive integration of theory with practice, group dynamics, and use of individual mentors. In particular, the goal of supervised early contact with patients can only be realized by involving mentors as practical guides. For this reason, the recruiting, selection and training of the mentors for their instructional tasks is a core responsibility in organizing the project. A significant amount of staff is required for this: in the first year of this project, three part-time staff members covering one full-time position supervised only 20 students in 20 teaching medical practices. From the perspective of the medical school in Halle, which supports this project with one annual full-time position, there are not only opportunities for presenting a positive image to the public and (state) government. It has also been possible to initiate potential partnership-based care models and (medical care) research projects through cooperation with teaching medical practices. In the case of positive evaluation of the first project phase (preclinical study) after two years, permanent inclusion of this project is planned in Halle. A program is then to be put into place in which the first General Practice Class participants would become licensed in 2017 and a total of up to 120 students would be able to participate over a course of 5 academic years (2 x 20 preclinic, 4 x 20 clinic/final clinical year). The project initiators are convinced that encouraging individuals and interest groups in regard to recruiting and fostering future primary care and rural physicians can also be more effective in Germany than distributing resources equally in a non-targeted manner [29]. The opportunities in small groups in terms of learning effect, group dynamics, cohesion, and shared career prospects are also utilized to counteract the danger of over-challenging the individual student [10], [17], [28]. The evaluation of the project will show in the coming years whether this assumption is correct.

Conclusion

Policy makers and society increasingly expect German medical schools to counteract a threatened shortage of general practitioners with appropriate measures during medical education. The elective compulsory course “General Practice Class” offers a feasible concept for accomplishing this.

Competing interests

The authors declare that they have no competing interests.