gms | German Medical Science

The status quo for trainees in Primary Care in Germany is one of little structure. Health policy makers as well as representatives of interest groups, health insurance companies, and primary care federations recognise that they must address an impending shortage of primary care physicians, particularly in underprivileged regions.

A number of general practice vocational training schemes have sprung up alongside the program for promoting training in General Practice [Article 8 Abs. 2 GKV-SolG i. d. F. des GKV-OrgWG from 15.12.2008 http://www.gesetze-im-internet.de/gkv-solg/art_8.html, last viewed 23.4.2013].

A hiatus must be anticipated until measures to secure the next generation of Primary Care physicians takes effect. It follows that in the foreseeable future the number of training posts will outnumber the number of doctors who are seeking them - which in turn favours developing the skills of trainers.

The skills demanded of budding General Practitioners will be a key area of discussion at the upcoming review of the existing training model by the German Medical Association. When viewed in the international context - with the exception of model projects such as "Verbundweiterbildung plus" [http://www.weiterbildung-allgemeinmedizin.de/, last visited on 04.23.2013] - it is clear that a comparable training program does not exist in Germany.

Training practices are not systematically and uniformly reviewed. As a result of German federalism there exists a patchwork of regulations throughout the regional medical associations, and the guidance offered by these organisations is hugely varied.

At the German Medical Assembly from 28.-31.5.2013 in Hannover it was decided that: "The German Medical Association must, as part of the revision of the training model (MWBO), consider how training is delivered in practices and clinics. The intention; to provide quality assurance for trainees and a uniform platform for the implementation of MWBO throughout the regional medical associations.

The Federal Chamber of Physicians was given this same instruction at the 114^th German Medical Assembly in 2011 in Kiel. At that time it was also highlighted that that in contrast to clear regulation for further training, there was huge variation in application between states and lacked transparency. There are significant differences between states both in the organization and delivery of training. The principle recommendations are brought together here. "[116. German Medical Assembly, summary of resolutions, http://www.bundesaerztekammer.de/page.asp?his=0.2.9807.11302, last viewed on 21.7.2013]

The haphazard manner in which vague guidance is currently applied [1] makes the development a consensus based Criteria Catalogue for General Practice trainees a logical first step. The catalogue is intended to serve as a guide to the training committees of the state medical associations.

Rotations in the outpatient setting are also planned for other specialities [2]. In the future these specialities will also have to address the development of criteria for training authorisation. In recent years there has been a dramatic fall in the number of new General Practitioners being registered. [http://www.bundesaerztekammer.de/downloads/Stat09Abbildungsteil.pdf, last viewed on 21.1.2014].

In contrast to other countries who employ a primary care system, in Germany it is possible to work as a General Practitioner with a variety of qualifications (Physician for General Practice, Practical Doctor (“Praktischer Arzt”), General medical physician working in primary care)

In 1999, German general medical physicians were required to decide whether they wanted to remain predominantly in a medical speciality or work as a primary care physician. The ability to switch directly from general medicine to primary care, can only be understood as a transitional arrangement - as numerous studies reveal that general medical presentations constitute only some 32-40% of Primary Care consultations [3], [4], [5] [http://www.content-info.org/public/berichtsband/CONTENT_Berichtsband_2.pdf, last viewed on 21.1.2014]. Accordingly it follows that training in general practice demands those missing surgical, orthopaedic and psychosomatic skills and competencies of its trainees, as well as specific knowledge of low-prevalence and low-risk areas of general practice. It is the task of the primary care community and their professional associations to describe the competencies required of their trade. No other professional group of a similar stature would allow itself to be dictated to by regional medical associations with regard to their training needs.

DEGAM herewith requires that - in keeping with european precedent - all GP trainers can demonstrate an understanding of, and can consequently consult on, the full spectrum of Primary Care medicine didactic competencies [6], [7].

The aim of the outlined criteria catalogue is to provide the state medical associations with a clear overview of training needs across the spectrum of primary care for those wishing to be engaged as trainers.

A first draft of the criteria catalogue was drawn up by a panel of Primary Care experts, and was intended to reflect the breadth of the speciality [http://www.degam.de/index.php?id=303, last visited on 04/23/2013] [8], [9] as well as picking out specific relevant competencies and skills.

The catalogue is divided into the following sub-headings (aside from certain “exclusion criteria” such as insufficient patient numbers and no home visits)

• Trainers previous qualifications
• Practice infrastructure
• Practice demographic

The catalogue was critiqued using the Delphi method, by way of the Board of the German Society of General Practice and Family Medicine (DEGAM), the DEGAM panels for training and education, the society for newly qualified General Practitioners in Germany (JADE [http://www.jungeallgemeinmedizin.de/tiki-index.php?page=Willkommen, last viewed 23.04.2013]), and the "List server of General Practitioners”.

Feedback from a total of 30 individuals or organizations was compiled in a narrative synopsis and re-released for review. This process was repeated three times. Any outstanding areas of contention were resolved by the 5 authors in a final consensus discussion.

The synopsis is available on the homepage of the Bremen Academy of primary care training [http://www.hausaerzteverband-bremen.de/uploads/media/SynopseRueckmeldungenKriterienWeiterbilderAllgemeinmedizin_3b.doc, last viewed on 21.1.2014].

Areas of particular contention included:

• Emphasis on chiropractic examination techniques of the musculoskeletal system
• Use of video camera for joint reflection and improvement of communication skills
• Standard “DEGAM” criteria
• Value of clinical tests in the practice
• Maximum assigned training period in one practice

In order to restrict the size of this article, the rationale for the individual items within the catalogue have been cut to a Web-Appendix [http://www.hausaerzteverband-bremen.de/uploads/media/Erlaeuterungen_zu_den_einzelnen_Items_des_Kriterienkataloges_fuer_allgemeinmedizinische_Weiterbilder.pdf, last viewed on 21.1.2014].

Preamble:

In order to be granted training practice status, primary care practices must fulfill specific minimum criteria within the three domains of

• Qualification of the GP trainer
• The patient demographic
• The practice infrastructure

Within each domain a minimum score of one third is required with the exception of the Infrastructure category where a minimum of half the total points available must be achieved.

The total score across the three domains determines the maximum training period granted. A few select criteria are defined as mandatory. NB: accreditation as a trainer in Germany has historically been assigned for a defined period of time (minimum 3 months to a maximum 36 months).

Some criteria include material provided by the German College of General Practitioners/ Family Physicians (DEGAM) these documents are available in german only.

Obligate criteria:

Primary care practices may operate as a training practice only if there is a consulting room and facilities available for the trainee in addition to those occupied by the trainer and other physicians within the practice.

Additional obligatory criteria include:

• At least quarterly review sessions between trainer and trainee (to allow reflection)
• Case review meetings at least weekly
• Continuously maintained quality management system
• Assistance finding a mentor for general practice education, if desired by the trainees. (i.e. an experienced practitioner to whom the trainee can turn for further guidance. This is explicitly not be the trainer, such that the trainee has the opportunity to discuss any issues arising from their training practice)
• The number of consultations per quarter numbers > 400
• The practice routinely carries out home visits

The qualification of the trainer is the most important determinant to being assigned trainer status (see Table 1 [Tab. 1]). Consequently it is to this domain that the greatest number of possible points are apportioned, with a minimum score of 10 from the 26 available required.

The authors felt that the domain “infrastructure” was less critical in assigning trainer status. Accordingly there are only 14 points available in this domain (see Table 2 [Tab. 2]). However the relative ease with which points can be accrued in this domain is reflected by a higher cut-off with a minimum score of 6 required.

As broad a spectrum of health care issues as possible were classified by the authors to the domains of the skills of the trainers and the infrastructure of the practice (see Table 3 [Tab. 3]). Because it was felt that the domain of practice demographic best reflects the whole breadth of primary care the required score is set even higher: to achieve training practice status a minimum of 10 of the 18 available points must be attained.

Maximum possible points: 58 points

Allocation of training status period:

Up to 24 months of training can be spent in practice according in this model. This limit ensures that should a prolonged training period be required the trainee with be offered a change of perspective.

Feasibility study:

In summer 2012, a feasibility study of the criteria catalogue was carried out in the primary care setting. Thirty general practitioners from the general practitioner list server as well as the DEGAM panels for education and training were engaged to provide socio-demographic data (age, sex, time in post, community size, formal qualifications, practice size) (see Table 4 [Tab. 4]). They also provided details of their own additional qualifications, experience as a trainer, the number of points achieved on the criteria catalogue and their subjective assessment of the outcome in terms of the period of allocated training status. This was supplemented by open questions for missing or superfluous criteria. The subjective satisfaction with the score achieved in the criteria catalog was correlated with the basic variables of age, gender, previous training experience etc.

62.96% of respondents were satisfied with the results of the criteria catalogue, 37.04% were not satisfied, and 3.70% were undecided (see Figure 1 [Fig. 1]). Analysis revealed that longer established trainers were more likely to be satisfied with the score achieved. There was no correlation between sex, experience as a trainer and the number of points achieved (and thus the allocated period of training status). Correlation was calculated using the Kendall rank correlation coefficient. The correlation between points scored and satisfaction was 0.105.

Most criticism was leveled at the criteria involving use of a videocamera, chiropractic, ultrasonography and those relating to DEGAM (training curriculum, feedback form, designation as a DEGAM-hospitation practice). The authors decided to retain these criteria. The detailed reasons are available in the web index [http://www.hausaerzteverband-bremen.de/uploads/media/Erlaeuterungen_zu_den_einzelnen_Items_des_Kriterienkataloges_fuer_allgemeinmedizinische_Weiterbilder.pdf].

Implementation of the catalog:

The DEGAM panels for training and education have approved the criteria catalogue. DEGAM is seeking an ordinance to define the qualification criteria for trainers in primary care in view of the forthcoming revision of general practice training by the German Medical Association and the German Medical Assembly. DEGAM seeks to disseminate these criteria through the German Academy of General Practice and state medical boards.

In this article a national and transparent set of criteria is proposed to determine the allocation of training status to prospective trainers in general practice. This proposal is a response to the sometimes unregulated, often widely disparate approach to training employed by the state medical boards. A targeted survey of all German state medical boards revealed a very mixed picture ((10)Alle Landesärztekammern wurden am 8.2.2013 angefragt. Zehn LÄK antworteten bis zum 22.3.2013. Eine Übersicht ist dargestellt, see Attachment 1 [Attach. 1], [10].

The strengths of the methodology employed are the use multiple feedback loops, the transparency of results and the implementation of a feasibility study. Weaknesses exist in the small number of participants, as well as selection bias of a particularly motivated group of GPs.

The greatest dissatisfaction with the criteria were the presence of a video camera, Chiropractic / Orthopaedics and DEGAM-related criteria (training curriculum, feedback form, guidelines and DEGAM-hospitation practice designation). The criteria are however intended to serve as a guide to change practice, not to discriminate.

The importance of the skills required to diagnose and treat disorders of the musculoskeletal system by means of additional chiropractic and/or orthopaedic training were outlined in detail in the catalogue. Some suggestions from the feasibility study were included in a revised version of the criteria catalogue. For example working in a rural location, and recognising Balint groups in different formats (for details refer to the synopsis, see Attachment 2 [Attach. 2]: Synopse).

An alternative to the suggested criteria catalogue would be to adopt an approach widely employed in several other countries, whereby a generic training period is granted on the basis of fulfilling certain minimum criteria rather than variable training periods. Such an approach might be required in the context of a shortage of primary care physicians - but it is felt this would not lead to the desired improvement in quality. Although primary care physicians performed best in an evaluation of the training of all medical specialities [http://www.baek.de/page.asp?his=1.128.6936, last visited 04.23.2013], the quality of their training holds much scope for improvement.

In 2009, an international commission of experts from Denmark, Great Britain and the Netherlands were invited by DEGAM to evaluate the German system of general practice training. The judgment of these experts was scathing [10]:

• No standardised curriculum
• No training for trainers
• Trainers were only selected on the basis of formal criteria
• Lack of formative assessment
• The role of the medical associations in determining training should be questioned, and this responsibility passed to the individual speciality body i.e. DEGAM and universities departments for general practice
• Training in Germany is clearly led by political rather than pedagogical considerations.

A comparison with the current requirements in different European countries shows that the core elements are handled quite differently (see Attachment 3 [Attach. 3]).

The requirements relate to infrastructure, didactic training of trainers and practice size. Feedback from other European countries, as was the case with participants of the feasibility study, identified a particular concern that strict quality criteria could deter potential trainers and possibly worsen the deficit in new general practitioners. This is countered by the fact that at this time there are significantly more general practice training posts available than are in demand.

Attractive models of good general practice training could prove to be a "competitive advantage" - and likely contribute to an improvement in the quality of training. The increased attractiveness of the training program can be indexed to the desire for improved quality.

This project deals principally with training for a career in primary care. It was further considered whether other specialities should introduce rotations in ambulatory care at the German Medical Assembly in 2013 in Hannover [http://www.aerzteblatt.de/archiv/140872/Entschliessungen-zum-Tagesordnungspunkt-IV-%28Muster-%29Weiterbildungsordnung, last viewed on 21.1.2014]. It is likely that a set of criteria such as those outlined here could be applied to other specialities. Though there is little evidence to support this - not least because currently there is minimal training taking place in the ambulatory setting in subjects other than general practice.

Following publication of these criteria, the authors aim to have the document accepted by the German Academy of General Practice at the German Medical Association. Subsequently these measures should be adopted and implemented universally by the state medical boards.

This criteria catalogue represents to the best of our knowledge the only proposal for a transparent set of criteria to impart a qualification as general practice trainer. In our proposal, both the breadth of general practice as well as the skill needs of the trainers are considered. The high level of satisfaction of participants in the feasibility study speaks for the validity of the proposed catalogue, which should now be adopted by the state medical boards. Individual components, in particular the process by which this catalogue was developed may serve other specialities as a blueprint for introducing outpatient training rotations.

We thank Professor Erika Baum at the Department of Primary Care, Preventative and Rehabilitation Medicine of the University of Marburg for her critical review of the manuscript. Also thank you to Dr Jan Islei for his help with translating the manuscript under difficult conditions.

The authors declare that they have no competing interests.