gms | German Medical Science

As of 2004, the amended German medical licensing regulations (ÄAppO) introduced interdisciplinary topics for the first time into German medical training. As a result, “prevention and health promotion”, designated as Querschnittsbereich 10 or Q10, has become an independent seminar topic with graded exam [1]. The amended ÄAppO and introduction of the interdisciplinary topics attached high expectations to improving the quality of medical education and reforming medical degree programs to meet new requirements in medical science and healthcare provision, as well as improving practical professional training [2]. With an interdisciplinary and subject-specific approach, these interdisciplinary topics in particular offer a chance to link clinical aspects with theory [3].

In respect to these interdisciplinary topics, legislators allowed universities a great amount of autonomy in terms of content and design. This, in turn, allows great possibility for target group-appropriate approaches based on regional structures. Although the importance of including preventive medicine subject matter in medical degree programs has for the most part been conformly recognized in Germany and internationally by governments and universities, heterogeneous implementation exists among universities [4], [5], [6]. Data on students’ topic-specific prior knowledge and their preferred teaching and testing formats had not been collected for the German-speaking countries and, therefore, could not be considered in discussions or curricular planning. Experience in England and the USA, however, demonstrate how meaningful such data can be. It was shown that the use of teaching methods considered innovative by instructors, but with which students had no previous experience, can pose an obstacle to effectively imparting information [7]. Teaching formats preferred by students change over time; at present in the western hemisphere, “Generation Me” predominates and is characterized not just by a high degree of intelligence, but also by an aversion to long texts and the desire for smaller curricular segments, multi-media presentations, problem-oriented approaches, and interactive components [8]. Even though student preferences alone cannot provide the only guideline for curricular development, international experience shows that effective curricular design can be successfully supported if student preferences and prior knowledge are taken into account not only in terms of what the prescribed subject matter should be, but also in terms of how it should be taught (“custom tailoring”) [9], [10]. Discussions held in advance between students and instructors to provide feedback on classroom experiences formed the basis for our data collection on student perspectives. Based on our planned curricular content, the students were surveyed in a cross-sectional study using a standardized questionnaire directly prior to the Q10 curriculum about subjective prior knowledge, the importance assigned to teaching objectives, preferred teaching and testing formats, and the relevance of topics in preventive medicine.

Students (n=220) in their fifth academic year at the Martin Luther University were surveyed during the introductory seminar to Q10 using a two-page, standardized questionnaire. Along with socio-demographic information (gender, age), the questionnaire asked for student scores on the preliminary medical examination. The questionnaire consisted of seven series of questions, of which two covered preferred learning and testing formats using multiple choice questions with additional opportunity to answer freely. Five question series on prior knowledge, assignment of importance to topics in preventive medicine, health risks, and content of healthcare consultations dealt with student assessments with 4-9 statements on each using five-point Likert scales. For all Likert scales, 1 indicated the strongest degree of agreement with a particular statement and 5 the strongest degree of disagreement. Instructor recommendations were followed and consensus was reached in advance regarding questionnaire length and design, as well as the choice and sequence of the answer categories [11].

Data analysis was performed using SPSS® (Version 12.0) to calculate frequency distributions, means (M), standard deviations (SD) and prevalence differences (PD). A dichotomy was undertaken to describe prevalence differences in connection with Likert scales by summarizing the degrees of agreement indicated by 1 and 2 as “predominantly agree”. For the sake of clarity, prevalence differences were given together with raw 95% confidence intervals (CI) in rounded form without decimals.

Of 220 registered students, 42% (n=94) filled out the questionnaire before beginning Q10. With an average of 92 respondents, very little missing data was seen within the question categories. Of the respondents, 65% were female (n=61). The mean student age was 25.3 years (SD=2.0). The mean score reported for the preliminary medical exam was 2.97 (SD=0.69).

Of the possible multiple choice answers, 75% of the students (n=70) indicated individual learning was the preferred learning format. This was followed by case-based learning and observational rotations with 54 and 49 responses, respectively. Issue-oriented study groups were named by 36 students and other interactive learning formats, such as seminar discussions, were named by 34 students. “Discussions of texts” was chosen the most infrequently with only 9 respondents selecting this format. Three respondents took the opportunity to answer freely and indicated a desire for “stronger practical relevance”, for example through more “bedside teaching”.

Male and female students differed in the information given on preferred learning and teaching formats. With 77%, women chose individual learning more frequently than men with 69% (PD=8; CI=(-12,27)); the same can be seen in terms of observational rotations with 55% of women in comparison to 45% of men (PD=10; CI=(-11,32)). With 5%, women named discussions of texts much less frequently than men did with 18% (PD=-13; CI=(-28,1)). Differences were also visible in connection with the preliminary medical exam score given: the group citing a grade of 1 or 2 (n=19) declared a preference for individual learning at a rate of 100% compared to 67% among those who earned a grade of 3 or 4 (n=71) (PD=33; CI=(22,44)). In contrast, students in the group with grades of 3 or 4 named case-based learning more often with 62% than those in the group with scores of 1 or 2 with 47% (PD=-15; CI=(-40,11)).

Regarding desired testing formats (multiple choice question), 90% (n=85) of the questionnaires submitted were evaluated. Student preferences were seen for “presentations with discussions in the seminar setting” followed up by subsequent written work (36 selected this preference = 42%) and for a “medical consultation on health promotion and subsequent case presentation to the seminar group” (31 chose this preference = 36%). In comparison, 13 preferred (=15%) written testing. Five students indicated a preference for other testing formats (option to respond freely) and in doing so included oral exams and group work.

The mean of all student self-assessed knowledge concerning nine different Q10 topic areas and competency levels was 3.45 (SD=0.95, n=838). Of those surveyed, between 11% and 28% rated their existing knowledge of individual Q10 topics, such as “methods for assessing risk” or “health consultation” as good or higher. In contrast, 60% designated their prior knowledge as “sufficient” or “deficient” in respect to “methods of risk assessment” and 48% made the same assessment for “risk-benefit analysis of screening programs”. Students saw themselves as relatively competent in the topics of “prevention programs”, “the role of the physician in health education”, and “identifying health promotion factors” with mean values of approximately 3.1 for each of the three. Knowledge of regional healthcare objectives in Saxony-Anhalt deviated clearly from the other assessments: 57% of those surveyed responded that their existing knowledge was deficient (mean=4.4), and this with 26% of the students having been born in Saxony-Anhalt (see Figure 1 [Fig. 1]).

For all student ratings of importance (n=744) for the eight Q10 focus areas in Halle, the mean lay at 2.6 (SD=0.9). The area of focus on “making decisions within the physician-patient relationship” tended to be rated as more important than the other topics with a mean value of 2.2 (SD=0.9): 68% of respondents considered it to be “important” or “very important” to learn more in Q10 and only 8% found it to be “less important” or “unimportant".

A proportion of 14% to 25% of respondents felt the remaining seven focus areas to be “less important” or “unimportant” – with the lowest values being seen for “critical reading” (see Figure 2 [Fig. 2]).

Of the eight preventive medicine topics offered, on average four were rated by both men and women as “important” or “very important”. 51% of the female students estimated the topic “population-specific preventive measures” to be “important” or “very important” compared with 33% of their male counterparts (PD=18; CI= -2,39)). The “importance of risk communication” was more frequently assessed as “important” or “very important” by female students (46%) in comparison with male students (34%) (PD=12; CI=(-9,33)). The attitude toward “critical reading”, however, is different: only 19% of female students viewed this as “important” or “very important”, while 48% of male students did so (PD= 29; CI=(-49,9)).

The importance of health risks to medical health consultation showed higher assignments of importance to risks stemming from the area of primary prevention. Health risks in the area of “lifestyle” (smoking, alcohol consumption, nutrition, physical activity) were viewed as “very important” by 64% of respondents (M=1.39, SD=0.5) and 44% (M=1.6, SD=0.6) identified the area of “psychological disease or overexertion”. “Environmental factors” and “genetic predisposition” were rated as tending to be less important for a medical consultation (M=2.2, SD=0.9). On average, five topics were seen as “important” or “very important” by men, while women indicated 6 topics on average (see Figure 3 [Fig. 3]).

Women rated all categories of health risks as “important” or “very important” more often than men: the most marked differences between the sexes were found to be regarding “genetic predispositions” with 73% vs. 51% (PD=22; CI=(2,43)), “environmental factors” with 80% vs. 62% (PD=18; CI=(-2,37)), and “social environment” with 86% vs. 75% (PD=11; CI=(-6,28)).

For their “own health-related behavior”, 53 of 94 students (56%) designated the topics covered in Q10 to be “important” or “very important” (M=2.4; SD=1.0). The relevance of the Q10 subjects to their “own professional medical activities” and “medical education in general” was estimated to be “important” or “very important” by 68% and 62% of the respondents, respectively. In respect to the specialty in general practice, prevention and health promotion were assessed by 89% of the respondents as being “important” or “very important” (M=1.6; SD=0.7). On average, women rated all four topics as “important” or “very important”, while men indicated an average of three topics. The clearest differences between men and women in the estimation of relevance were found to lie in the importance concerning their “own professional medical activities” with 73% of women students citing this in contrast to 57% of male students (PD=16; CI=(-4,37)) and concerning the students’ “own health-related behavior” with 67% compared to 36% (PD=31; CI=(11,52)).

The distribution for the degrees of agreement with five thesis statements on prevention shows marked differences; even in cases of more complex wording, polarized assessments were frequently seen. The two following statements conceived of as opposites, “decisions are made together during the physician-patient consultation” and “health-relevant decisions are made by the physician”, show a contrary agreement distribution. Although 84% of respondents “agree very strongly” or “agree” with the first statement, only 49% reject the opposite statement with “disagree completely” or “disagree”.

The statement that “healthcare insurance providers do not profit from the support of preventive measures” was rejected by 79 students (=83%) with “disagree completely”. The effectiveness of the previous medical curriculum on the topic of health promotion is rated with an average agreement value of 3.4 (SD=0.8) and a percentage of 42% responded with “disagree” or “disagree completely”. Men and women agreed with an average of two of four given statements (see Figure 4 [Fig. 4]).

In respect to the statement that “health-relevant decisions are made by the physician during patient consultations”, women agreed less often than men with 20% in comparison to 31% (PD=-11; CI=(-30,8)). The statement “each person bears the responsibility for taking health-related risks” met less often with agreement from female students (52%) than it did from male students (60%) (PD=-8; CI=(-29,13)).

The established Q10 curriculum and teaching objectives were described by Walter et al. in a survey on the implementation of Q10 at medical schools in Germany in 2007. As an investigational field, the Martin Luther University provides a typical example of Q10 in Germany with the curricular content being presented in the fifth academic year, its initial implementation having been in the 2004 summer semester, and its consisting of a combination of lectures with seminar courses [4]. This study had an exploratory objective and a separate pre-testing of the survey instrument did not take place. The option to answer freely, including the possibility to criticize the questionnaire, was seldom made use of. A small percentage of missing data (approximately 2%) in the collection indicates adequate processing time, comprehension of the questions, and modes for answering. The low proportion of participants, 42%, makes it difficult to apply the results generally since little is known about the non-participants. Age, sex, and preliminary exam scores did not deviate noticeably from those of all registered students for this particular academic year. Low power leads to imprecise estimation of effect sizes. Particularly when considering the prevalence differences regarding gender-specific differences, it is noticeable that the confidence intervals include the value 0, and thus the possibility that “no difference exists” cannot be excluded.

The preference for individual learning by students at the Martin Luther University contrasts with the general student preferences for internships and seminars named in the literature [11]. Students with “better” scores on the preliminary medical exam prefer individualized learning; it is possible that autodidacts possess a greater capacity for abstract thought and find group discussions take up large amounts of time and are less effective for learning. A possible explanation for this could be negative student experiences with interactive teaching concepts over the course of the degree program. The learning formats preferred by students encompass case-based learning – as recommended and positively evaluated in the international literature in discussions of innovative teaching concepts for Q10 topics [12], [13]. Student preference for testing in the form of a presentation contrasted with a rarely desired written exam. For the Q10 program, however, 86% of the German medical schools require a written test – predominantly in the form of multiple choice answers and for 87% of these, this provides the sole measure of learning [4]. Limited personnel resources and the restricted possibility for demonstrating knowledge of preventive medicine topics on written tests very possibly take both economic aspects and student preferences into consideration by allowing the use of “presentations/case presentations in the seminar setting” as an exam format.

According to their estimations, students at the Martin Luther University acquired little knowledge of preventive medicine during the first four years. In particular, it is possible that key competencies in preventive work with clinical relevance, such as “methods of risk evaluation” or “health consultation”, were not sufficiently taken into account by the prior program curriculum. At the Martin Luther University and at 40% of all medical schools, Q10 is offered in the fifth academic year [4]. It is conceivable that upon consideration of learning objectives in an interdisciplinary light, Q10 topics should be given earlier and broader coverage in the curriculum – such studies are available for the Anglo-American educational system [14], [15]. However, it is also possible that simply exposing students to preventive medicine topics could have remained without a learning effect because this does not use individual experience of preventive medicine in practice as a didactic tool [16].

Assignment of importance by students to example Q10 focus areas demonstrated uniformly lower values than the data collected nation-wide from the Q10 instructors (also via five-point scales). Only the focus on “making decisions within the physician-patient relationship” was rated by students nearly as it was by the surveyed university instructors to be “important” or “very important”. These results underscore the need for motivational and effective communication of Q10 topic relevance before and during the interdisciplinary unit [4]. Systematic planning of interdisciplinary instruction should therefore encompass its integration across the length of the overall curriculum and not just remain in the curricular implementation of interdisciplinary topic segments [17].

An educational objective for Q10 is the training of future medical doctors to competently hold discussions with patients with the aim of preventing chronic diseases. To accomplish this, health risks must be recognized and assessed. However, for physician-patient consultations students prefer the “discussable” risks from primary prevention. Risks such as “environmental factors” and “genetic predisposition”, which are not typically primary preventive ones, are held as tending to be less relevant. With physicians having a medical function – important not only in primary care – as “health coaches” for chronically ill and multimorbid patients, Q10 curriculum should also take secondary and tertiary preventive aspects into account sufficiently. This was similarly assessed by the university instructors surveyed by Walter et al. [4]: between 86% and 97% estimated such topics as “important” or “very important” and integrated them into teaching concepts [4]. In case-based teaching models for promoting prevention with mandatory contact with patients, a mix of various prevention levels can be addressed, and thus be additionally effective in terms of instruction [18].

It is positive to see that the complete spectrum of Q10 topics is frequently assessed as “important” or “very important” by students, with female students standing out especially. Interestingly, this indicates a high degree of initial motivation on the part of the students – even when this was not explicitly asked about. The challenge facing curricular development is to sustain this initial motivation and use it for successful learning, while at the same avoiding over-structuring or over-loading the curriculum. It would be interesting to conduct a survey of medical students across multiple universities and independent of academic year regarding Q10 topics and beyond to find out about previous experiences with different teaching concepts.

Student participants preferred individual learning as the learning format for Q10; this was supplemented by case-based learning and observational rotations. In terms of testing for knowledge, seminar presentations on topics in the literature or case presentations were cited as favorites. Written exams met with little approval. Students’ assessment of their existing knowledge of Q10 subject matter is low. In respect to health promotion, student participants focused more on “treatable risks” and less on secondary or tertiary preventive aspects. Respondents gave the content of Q10 a high degree of relevance for their own health-related behavior and professional medical activities. Despite our relatively small and monocentric sampling, a high level of implicit motivation in the students can be recognized. We view these results as valuable for on-going improvement of our curriculum in terms of closed quality management of the instruction and for further studies – ideally across multiple locations – concerning target group-specific curricular development.

The authors declare that they have no competing interests.