International electives in the final year of German medical school education--a student's perspective.

The final year of medical school has a unique role for introducing students to their future responsibilities and challenges. At many medical schools, electives at an accredited institution abroad are a common part of the student's final year experience. International electives provide an opportunity for a personal and academic experience that will often create new perspectives on clinical medicine and research, medical education and healthcare policy. In this article the authors reflect on their experience as elective students abroad and discuss the contribution of international electives to the constant development and progress of local final year rotations. They identify key areas for improving final year electives and outline essential features for a valuable and successful final year elective.

Personal opinion

“In what may be called the natural method of teaching, the student begins with the patient, continues with the patient, and ends his studies with the patient, using books and lectures as tools, as means to an end” - Sir William Osler [1]

In his truly fascinating 1901 essay, Sir William Osler, then professor of medicine at Johns Hopkins Hospital, takes us through his school’s curriculum for medical students at the turn of the twentieth century. He describes the curriculum’s fourth year, the final year of the program, as the time where the student “sees close at hand the unwashed maladies, not the distant prepared and altered picture of the amphitheater”, a time in which the student is “responsible for the history of the case, the daily records, and (…) personally does all the blood and urine work, or minor operations” [1]. Although more than a century of ground-breaking biomedical discoveries, great advancements in our medical practice and profound changes within healthcare systems have shaped the way medicine is practiced and taught throughout the world, the significance of the final year of medical school for introducing the young student to his future responsibilities and challenges remains the very essence of teaching clinical medicine in medical school.

Medical school’s curricula in Germany have undergone important reforms in the past decade, which include key areas of final year medical education [2], [3], [4]. The final year (“Praktisches Jahr”) now consists of three different phases: There are two mandatory rotations in medicine and surgery of four months duration each, while students can choose a third specialty (such as pediatrics, neurology and others) for the remaining four months. Training within each four month block (or two month block in some cases) can be spent in a variety of subspecialties and usually involves time with the in- and outpatient service at a university hospital or affiliated teaching hospital. Recent amendments to national medical licensing regulations (“Erste Verordnung zur Änderung der Approbationsordnung für Ärzte”) allow students to spend their final year rotations at any accredited academic medical center within Germany, therefore allowing greater mobility and enabling students to train at teaching hospitals outside their own medical school. This is an important and novel opportunity, as it allows students to gain insights into different residency programs that they might consider applying for and it also, to some degree, creates competition between academic medical centers in the attempt to recruit the best final year medical students. A rotation at an accredited general practitioner’s office has been recently introduced as a separate track, which is part of the increasing efforts to encourage students for future training in family medicine. Although training objectives, supervision and mentoring are often not clearly defined or are subject to the individual standards of the respective medical school, department or teaching hospital, there is a broad consensus that the final year of medical school is key to introducing students to their future working environment. Ideally, final year medical students act as sub-interns and as such are integrated into the team. They are expected to perform all routine tasks in patient management such as admitting and following patients, performing minor procedures, such as intravenous cannulation or lumbar punctures and take call or weekend shifts. Hence, final year students have the unique opportunity to acquire important skills and knowledge in a setting that suits their experience. They may nearly resume the role and responsibility of a junior resident, which they will be within a year's time. While most departments enable students to have a valuable educational experience, the important role of the final year as a bridging time that allows the transition from a student to a resident with full responsibility for the care of his/her patients is constantly endangered by time constrains, load of tasks not beneficial to the student’s learning objectives and senior doctors' lack of teaching and advice. Many German medical schools and teaching hospitals have therefore implemented a number of measures to ensure the quality of their final year rotations and are constantly working to improve the curriculum for their current and future students (authors' personal experience and [3], [5]).

As a separate track, a large number of German final year medical students spend a period of their training abroad, commonly at North American, British, Swiss, Australian or South African medical schools (authors' personal experience and [6]). Although there are as many reasons for an elective abroad as there are accredited institutions, one motivation often heard is the hope for high-quality, dedicated and personal clinical teaching. Some medical schools have already established formal elective programs with foreign medical schools and these agreements usually allow a small number of students to train abroad with full credit for the time spent at the host institution. However, many programs are limited and therefore subject to a competitive selection process. As final year medical students we had the opportunity to experience teaching at three different medical schools in the United States of America and United Kingdom. The following essay highlights our experience abroad and reflects on the implications for final year medical education at German medical schools.

What is the motivation to go abroad for a clinical elective as a final year student?

An elective abroad is a unique international experience, both personally and academically, that opens new perspectives on clinical medicine and research, medical education and healthcare policy. Students are often assigned to a particular team or attending physician, have clearly defined roles and responsibilities and often enjoy personal mentorship. While just like in most rotations in Germany, the exact schedule and objectives of the elective depend on the reciprocal relationship between the student and the team, in our experience teaching medical students and junior doctors is considered an essential aspect of the attending’s or team’s daily routine and as such is highly emphasized. Students are encouraged to follow an adequate number of cases and to responsibility for their assigned patients, including all aspects of care from admission to discharge. They have the chance to admit patients to the service, present cases to the team, order diagnostic tests, perform routine and advanced procedures and decide medical management with guidance and supervision. Teaching usually takes place during ward rounds when students are challenged to present the case in a concise and structured format and to propose a preliminary diagnosis, differential diagnoses as well as a diagnostic work-up and management plan. These presentations will often be used by the attending to facilitate certain teaching points or to discuss peculiar aspects of the case. Formal teaching opportunities for students include daily noon-conferences and weekly journal clubs, case discussions and grand rounds.

What can we learn from this way of educating medical students?

It seems very simple: Students have to be valued and treated as future colleagues, appreciating and fostering their contribution to patient care at a professional level that suits and constantly extends their yet evolving clinical skills. Students have a need to experience close mentoring as they struggle to constantly extend their share of responsibility for their patients. They should be formally assigned to the team’s attending or senior physician to allow efficient mentoring. An elective catalogue should be established at every medical school and should include a description of the elective with defined learning objectives, assessment methods and participating faculty. Concise information on the student’s role and responsibilities should be provided and should be discussed at the beginning of each rotation. This goes hand-in-hand with a need for a new “culture of teaching” that adds teaching to the daily routine of each ward team and that ensures that students are only provided with tasks beneficial to their learning objectives. Ideally, every team member should commit to teaching students on their service and it should be clear that it is the attending’s responsibility that goals for the student’s rotation are defined, discussed and met. Students should be assigned a list of patients that they will cover and follow for the entire stay on their service, providing all aspects of patient management with guidance and supervision by the team. A “co-sign policy” could be implemented allowing the student to develop a treatment plan and write orders that will be revised and validated by the resident on the case. The student’s presentation of the patient should be a natural part of ward rounds, giving the student a forum to present their knowledge to the team.

Daily clinical work should be supplemented with formal didactic sessions such as noon conferences, small-group bedside teaching and scheduled teaching rounds with senior clinicians. Engagement of students in case presentations or clinical research projects is often highly appreciated and students should be given the opportunity to present an interesting case at the end of each rotation, write a case report or contribute to a research paper. The impact of these opportunities is often profound as it will often create a deep interest in a disease, subspecialty or research area and therefore might encourage students to strive for a career as a physician-scientist.

Feedback by the attending or senior team members during as well as at the end of each rotation, with a personal discussion of the student’s performance and progress, is very helpful and will further enhance the student’s commitment. Vice versa, students should formally evaluate the quality of teaching during the rotation. Reciprocal feedback will hopefully aid in developing a new and sustainable “culture of teaching”.

Along with constantly improving final year curricula, German medical school should extend existing elective or exchange programs with foreign medical schools and should particularly encourage electives at North American and British medical schools. Financial support should be offered and could be partly funded by dedicated foundations and alumni organizations. Creating international electives and mutual exchange programs will foster future collaborations and will raise opportunities for training and research. We therefore argue that international electives are a key component of final year curricula and as such can provide valuable guidance for constantly improving local final year rotations.

In this spirit, Sir William Osler, too, acknowledging the great opportunities of a training abroad, became an international elective scholar and as such was a student at leading medical centers of his time in Berlin, Vienna and London.

About the authors

In 2012, the authors have been visiting final year medical students at Columbia University – College of Physicians and Surgeons, New York, USA (D.E.-F.); at Johns Hopkins School of Medicine, Baltimore, USA (M.A.) and at Oxford University, Oxford, UK (L.W.). In this “by students” article the authors reflect on their experience abroad and identify key areas for improving final year rotations in Germany.

Disclosure

D.E.-F., M.A. and L.W. received support by the German National Academic Foundation (Studienstiftung des deutschen Volkes e.V.); D.E.-F. received support by the German National Exchange Service (Deutscher Akademischer Austausch Dienst). The funding agencies had no role in the design, preparation or writing of this manuscript.

Acknowledgement

D.E.-F., M.A. and L.W. received support by the German National Academic Foundation (Studienstiftung des deutschen Volkes e.V.); D.E.-F. received support by the German National Exchange Service (Deutscher Akademischer Austausch Dienst). D.E.-F. and L.W. would like to thank the staff at the Studiendekanat der Medizinischen Fakultät Heidelberg, in particular Mrs. Barbara Lampe, M.A., Professor Franz Resch, Dean of Students, and Dr. Roman Duelli, Chief of Dean's office, for their support. M.A. would like to thank the staff at the Studiendekanat der Medizinischen Fakultät Mannheim, in particular Ms. Claudia Dittmer and Professor Harald Klüter, Dean of Students, for their support. The funding agencies and supporting institutions had no role in the design, preparation or writing of this manuscript.

Competing interests

The authors declare that they have no competing interests.