The profession of medicine: a joint US–German collaborative project in medical education

Abstract

Background: International collaborations between medical institutions occur frequently in research and clinical training, but less often in undergraduate medical education. Collaborative programs in psychosocial, ethical and cultural topics are rare. “The Profession of Medicine”, an elective undergraduate course based on the “Patient, Physician and Society” curriculum at Northwestern University's Feinberg School of Medicine in Chicago, USA, was introduced in 2005 at the Charité–Universitätsmedizin Berlin, Germany, in order to provide students with a learning opportunity in this field and to introduce an international context to student education.

Methods: The five-day course is offered to preclinical medical students twice a year and includes topics such as cultural diversity, end of life issues, mistakes in medicine, vulnerable populations, and interactions with the pharmaceutical industry. The course language is English, in a format consisting of both plenary and small group sessions. To date, one-fifth of the instructors have been from the U.S. institution. Educational methods include small group discussions, presentations by guest speakers, movie and video clips, role plays, and reading and writing assignments.

Results: The participants have evaluated the course very favourably, with average scores ranging from 1.2 to 1.5 (1 = best/agree the most and 5 = worst/agree the least). Pre- and post-course self-assessment with regard to knowledge, interest and professional attitude revealed a statistically significant increase for all course topics.

Conclusions: In sum, the integration of Northwestern University's Feinberg School of Medicine's “Patient, Physician and Society” course concept into the Charité - Universitätsmedizin Berlin has been an effective method to develop students' professional skills and to stimulate international educational collaboration.

Background

Owing to groundbreaking reforms in medical education in the U.S. in the eighties (Association of American Medical Colleges 1984), by the mid-nineties courses devoted to communication skills, personal and professional ethics, medical humanities and behavioural sciences had become incorporated into educational programs as integrated, comprehensive curricula at many U.S. medical schools (Makoul & Curry 1998b). The “Patient, Physician and Society” course is one such curriculum, introduced at Northwestern University's Feinberg School of Medicine in 1993. Initially encompassing about 30% of the first and second year curriculum at Northwestern, and now extending into the third and fourth years as well, the course is designed to provide a comprehensive, integrated introduction to professional skills and perspectives, and to familiarize students with the concept of patient-centred medicine. Curricular units address such topics as personal and professional ethics, medical humanities, behavioural sciences, physician-patient communication, health services organization and financing, the health of vulnerable groups, and cultural dynamics in medicine. Course sessions focus on active and interactive learning formats, with an educational philosophy of encouraging students to find answers on their own (Makoul & Curry 1998b; Montgomery et al. 2003).

Table

Practice points
•Comprehensive courses in professional skills and perspectives have become a common curricular component in U.S. medical schools.
•The “translation” of one of these courses to a medical school in Germany was well received by students electing the course.
•Among the many benefits of this collaboration, a meaningful inter-institutional relationship has developed between the two schools.

In Germany, reform efforts in medical education have also been under way (Murrhardter Kreis 1989, 1995; Wissenschaftsrat 1992), but have not to date resulted in comprehensive curricula such as those described by Makoul & Curry (1998a, b) in the United States. Nevertheless, innovative courses, projects, and reformed curricula emphasising the psychosocial, ethical and cultural dimensions of medicine have been developed and offered sporadically through individual efforts, through both faculty and student initiatives (Schüppel et al. 1998; Kiessling et al. 2003; Schildmann et al. 2004; Burger 2006).

The Charité–Universitätsmedizin Berlin is Germany's largest medical school, formed in 2003 by the fusion of the medical faculties of Humboldt University (in the former East Berlin) and Free University (West Berlin). In Germany, medical education is based on a six-year medical curriculum, divided into a preclinical part (first and second year), a clinical part (third to fifth year), and a final practical year. All courses are typically in German, are required, and are taught in lecture-style formats, seminars, bedside teaching and practical training (Pabst 1995). In 2003, licensing regulation reforms went into effect, mandating one elective course in each of the preclinical and clinical stages of the curriculum (Von Jagow & Lohölter 2006).

International collaborations and interactions between medical institutions occur frequently in the fields of research and clinical training, while less frequently in undergraduate medical education (Armstrong & Fischer 2001; De Vries et al. 2002; Imperato 2004; Margolis et al. 2004; Finkel & Fein 2006). To our knowledge, no international partnerships between medical schools have been described in the field of psychosocial education and professional skills. In this report, we present the course “The Profession of Medicine”, the implementation of a joint international project in this area of undergraduate medical education between Charité–Universitätsmedizin Berlin, Germany, and Northwestern University Feinberg School of Medicine Chicago, U.S.A. The course is founded on the concepts and borrows from the content of Northwestern's “Patient, Physician and Society” curriculum, and was introduced at Charité–Universitätsmedizin Berlin in 2005 as an elective during the preclinical stage of medical school.

Course description

Course topics are guided by the content and philosophy of the “Patient, Physician and Society” curriculum at Northwestern University's Feinberg School of Medicine (Makoul & Curry 1998a, b) and are currently devoted to the following subjects: Cultural Diversity in Medicine, Making Mistakes, End-of-Life Issues, Vulnerable Groups, and Interactions with the Pharmaceutical Industry. The course has the following four educational objectives: (1) to cultivate interest in and respect for the values that characterise medical practice, (2) to encourage attention to the social, cultural, and ethical aspects of medicine, (3) to consider the experiences of the patient, family and physician, and (4) to introduce students to situations and problems that they will likely deal with as physicians. The course director is typically assisted by four student teaching assistants or co-instructors who have participated in the course in a previous session. They are oriented to small group teaching in a pre-course meeting with the course director, and receive a small stipend.

The course is a week\long seminar, offered as an elective during the final weeks of spring and autumn break. The daily course sessions are each three hours long, and divided into three parts. During the first hour, the topic is introduced, typically with a “trigger tape” followed by a short discussion with the whole group. In the second hour, the class divides up into small groups of 6–8 students, each led by the course director or a teaching assistant. In the third hour, the entire class meets again in order to present the small groups’ discussion results as a role play or in a debate, or to listen to a guest speaker's presentation on the topic.

Registration is open to all students enrolled in the preclinical years at Charité–Universitätsmedizin Berlin. The course is announced via a medical student internet forum and student mailing lists. Acceptance in the course follows a first come, first serve basis, up to a maximum of 40 students. The course syllabus is sent to the students via electronic mail approximately 6–8 weeks prior to the beginning of the course.

Medical school policy requires that the course be graded, and stratified into “sehr gut” (very good), “gut” (good), “befriedigend” (satisfactory), and “ausreichend” (sufficient) categories. This is accomplished through a point system based on attendance, participation, knowledge, and quality of the writing assignments.

Course evaluation as of August 2006

By August 2006, a total of 142 students had participated in the course during four different sessions. Almost 75% of participants to date have been female, compared to a female student body of approximately 64% at the Charité–Universitätsmedizin Berlin (Humboldt–Universität 2005).

Questionnaires. Upon the conclusion of the course, students completed a questionnaire addressing course content, efficiency, and the quality of instruction. They rated the course very favourably, with average scores between 1.2 and 1.5, with 1 being the best, 5 being the worst value (Table 1). Students indicated a high propensity to recommend the course to others, and in fact more than 50% were taking the course based on recommendations by previous course participants.

Table 1.  Course evaluation

	Average score	Range
Course topics	1.3	1–3
Course director	1.2	1–3
Efficiency	1.5	1–5
Relevance	1.3	1–4
Overall impression	1.3	1–3
Recommendation to other students	1.2	1–3

Results of n = 136 responses. Students were asked to rate their answers on a scale of 1 to 5, with 1 being the best, 5 being the worst value.

Students were also asked to rank their motivations to participate in the course. The most important of these was the choice of course topics, followed by the fact that the course was given in English (Table 2). Timing was an intermediate factor, and place and ease of getting a certificate were rated as of lesser importance.

Table 2.  Course motivation

	Average score	Range
Interesting topics	1.4	1–5
Course in English	1.6	1–5
Convenient time	2.1	1–5
Easy to get a certificate	3.0	1–5
Convenient location	3.2	1–5

Results of n = 70 responses. Students were asked to rate their reasons for taking the course on a scale of 1 to 5, with 1 being the most important, 5 being the least important.

Pre- and post - course surveys. In order to obtain information about educational outcomes, students were asked to estimate their knowledge, interest and professional attitude pertaining to the course topics by completing surveys before and after the course. Pre- and post course self-assessment scores were compared via a t-test applied to all three variables of knowledge, interest and professional attitude. Pre-course knowledge was low, with a statistically significant increase in all five course topics after completion of the course. The lowest pre-course knowledge was for the topic “Interactions with the Pharmaceutical Industry”, the highest for “End-of-Life Issues”. The highest increases in knowledge occurred for the topics “Vulnerable Groups” and “Interactions with the Pharmaceutical Industry” (Figure 1). Students’ pre-course interest was already very high before the course, with the highest values given to the topics “Mistakes” and “End-of-Life Issues”, and the lowest values to “Vulnerable Groups” and “Interactions with the Pharmaceutical Industry”. The increment in interest after the course was still statistically significant in three topics, namely “Mistakes”, “End-of-Life Issues” and “Interactions with the Pharmaceutical Industry”. The topics of lowest pre-course interest (“Vulnerable Groups”, “Interactions with the Pharmaceutical Industry) remained of lowest interest after the course (Figure 2). The pre-course professional attitude was already significant before the course, with the highest values given within the areas “Mistakes” and “End-of-Life Issues”, and the lowest values within “Cultural Diversity” and “Interactions with the Pharmaceutical Industry”. The improvements after the course were still statistically significant, with the greatest change occurring for “Cultural Diversity” and “Interactions with the Pharmaceutical Industry” (Figure 3).

Figure 1. Result of pre- and post-course surveys assessing students’ knowledge of the course topics. Students were asked to rate on a scale of 1 to 10 (0 none, 10 = the most) to respond to the question: “How would you rate your knowledge of: (a) Cultural diversity in medicine; (b) Making mistakes in medicine; (c) End-of-life issues; (d) Vulnerable groups in medicine; (e) Interaction with the pharmaceutical industry?” N = 142 pre-course survey responses. N = 133 post-course survey responses.

Figure 2. Result of pre- and post-course surveys assessing students’ interest in the course topics. Students were asked to rate on a scale of 1 to 10 (0 none, 10 = the most) to respond to the question: “How would you rate your interest in the subject of: (a) Cultural diversity in medicine; (b) Making mistakes in medicine; (c) End-of-life issues; (d) Vulnerable groups in medicine; (e) Interaction with the pharmaceutical Industry?” N = 142 pre-course survey responses. N = 133 post-course survey responses.

Figure 3. Result of pre- and post-course surveys assessing students’ professional attitude toward the course topics. Students were asked to rate on a scale of 1 to 10 (0 none, 10 = the most) to respond to the question: “How would you rate your degree of responsibility as a future physician toward patients and society in the context of: (a) Cultural diversity in medicine; (b) Making mistakes in medicine; (c) End-of-life issues; (d) Vulnerable Groups in Medicine; (e) Interaction with the Pharmaceutical Industry?” N = 142 pre-course survey responses. N = 133 post-course survey responses.

Discussion

Contributions to social aspects of medical education in Germany

In the middle of the nineteenth century, Rudolf Virchow, the father of modern pathology, commented on the scope of medicine's role in society: “Die Medicin ist eine sociale Wissenschaft, und die Politik ist weiter nichts, als Medicin im Grossen" (Medicine is a social science, and politics is nothing else than large scale medicine) (Wittern-Sterzel 2003). After 150 years, this realisation has not lost any of its significance. The course “The Profession of Medicine” is based on Virchow's observations and, interestingly and quite coincidentally, is held just one block from his former work place at the Charité Berlin.

Despite Virchow's prescient understanding of the social role of medicine, German medical education has traditionally had a very strong emphasis on scientific and theoretical training while under-representing the psychosocial and some of the practical aspects of medicine. In a survey of 671 medical graduates from seven German medical schools in 2002, the top three deficits reported were in the areas of practical skills, physician-patient interaction and psychosocial competency. The respondents deplored how poorly they felt prepared for the non-scientific tasks and challenges of a medical practice (Jungbauer et al. 2004). An earlier paper examining the role of basic professional competencies in the German medical education system also describes significant shortcomings with regard to psychosocial issues, communication skills and medical ethics (Perleth 1998). These works suggest that many medical school graduates in Germany feel overwhelmed and cheated by their education when, as practising professionals, they face such inevitable issues as death, mistakes, and cultural diversity among their patients with no formal preparation in these areas.

One of the explicit purposes of the course “The Profession of Medicine” is to specifically address some of the topics underrepresented in the current German medical education system. Judging from the written and oral feedback to the course, this goal seems to have been achieved to a considerable degree. Suggestions have even been made by the students to expand the course and to integrate it into other phases of medical education beyond the preclinical stage, and to make it a mandatory and regular rather than an elective component of the curriculum. Since 75% of the enrolees of “The Profession of Medicine” have been women, a mandatory course would be particularly useful to ensure the introduction of men to the more humanistic aspects of medical education.

Among the many topics covered in the “Patient, Physician and Society” curriculum at Northwestern University's Feinberg School of Medicine, only five could be integrated into this one-week version at Charité–Universitätsmedizin Berlin. The five topics were carefully chosen, each encompassing a certain degree of social and professional taboo. It is important to lift the silence surrounding these issues. This is particularly important in face of the fact that today's graduating physician faces a very different patient population than in the past, a more proactive population armed with internet education, expectations of cultural sensitivity, and demands for honesty, information, and choices from their medical practitioners.

Multiple movements from within society have encouraged changes within medical education–immigrant initiatives (Fox 2005), gender equality (Vlasoff & Garcia Moreno 2002), the hospice and palliative medicine movement (Emanuel et al. 2000), patient safety initiatives (Wachter et al. 2002), and the evolving standards of medical ethics (ABIM Foundation et al. 2002), to name a few. The vitality of these movements is made apparent to our students by the willingness of guest speakers to offer presentations during “The Profession of Medicine” about their various projects, including medical assistance for undocumented immigrants, women and disability, assistance for victims of domestic violence, and mental health issues of immigrants. The topics have also encouraged the students to question the traditional paternalistic model of patient care in light of a more patient-centred, egalitarian patient-physician relationship.

Student surveys both before and after the course generally rated the “Mistakes” and “End-of-Life Issues” topics as more interesting and important than “Cultural Diversity in Medicine”, “Vulnerable Groups”, and “Interactions with the Pharmaceutical Industry”. Perhaps the former topics, which deal more directly with personal aspects of the patient-physician relationship, were more effectively addressed in these brief sessions than were larger, more complex social issues. Traditional notions of the physician's greater responsibility toward the individual patient than toward society as a whole may also be at work here.

Contribution to international medical education

Significant developments in medicine have come from international communication among scientists and clinicians around the world (The Executive Council, The World Federation for Medical Education 1998). The accelerating globalisation of medicine was specifically kept in mind when the course “The Profession of Medicine” was established, with the intention of exposing students to transnational similarities as well as cultural differences in the psychosocial, cultural and ethical aspects of patient care. The course is taught in English in order to give students the opportunity to apply the international language of medicine in speaking and writing (Maher 1987).

This course project has facilitated the development of an institutional alliance between Charité–Universitätsmedizin Berlin and Northwestern University Feinberg School of Medicine Chicago, with an ongoing student exchange in clinical medicine and prospects for additional levels of institutional collaboration. One Northwestern medical student has also already served as a teaching assistant and small group preceptor in the course at Charité–Universitätsmedizin Berlin, in fulfilment of the fourth year curricular requirement at Northwestern for a supervised experience in teaching.

Contributions to methods in medical education

Teaching methods drawn from experiential education methods–role play, discussion-based seminar formats, and reflective writing techniques, for example–have gained wide acceptance in U.S medical curricula over the last two decades. In the course “The Profession of Medicine”, learning was primarily achieved by these more active and interactive means, and our students found them effective. Despite the introduction of these learning methods in several curriculum reform projects (Kiessling et al. 2003; Schildmann et al. 2004; Burger 2006), much of German medical education remains rooted in more traditional methods. We hope to have contributed to the acceptance of newer educational principles and methods through the introduction of this course.

Unresolved issues

For practical reasons, only a very small portion of the “mother” curriculum “Patient, Physician and Society” could be introduced at Charité–Universitätsmedizin Berlin. Due to the ironies of course scheduling, it has not yet been possible to involve students from the Reformstudiengang, or “Reform Curriculum,” a vibrant and progressive component of the Charité–Universitätsmedizin Berlin educational programs (Burger 2006). Resolution of these logistical issues would create new opportunities for further curriculum development and intra- as well as inter-institutional collaboration. Other logistical barriers will remain, however, not the least of which is difficulty in providing small group settings to the large Charité–Universitätsmedizin student body, which is nearly eight times the size of the student body at Northwestern.

Some students thought the predominance of reading materials from English-language medical journals created an over-emphasis on U.S. perspectives. On the other hand, with only the occasional American faculty member or student in attendance, the literature provided some assurance of an international component to class discussions.

The Charité's Office of Medical Education requires a scaled grading system with five grades, the worst grade being equivalent to failing the course. The authors were not in favour of this grading method; they would have preferred a pass-fail grading system, as is the case for the course at Northwestern, to help keep a population of highly competitive students focused on the course topics rather than on concerns and ambitions surrounding their grades. The students in “The Profession of Medicine” were consequently graded rather leniently. Although student evaluations revealed that “ease of getting a certificate” was rated as of lesser importance (Table 2), the possibility of the course developing a reputation as an “easy pass” remains unresolved.

Future prospects

Despite upcoming changes in course leadership, “The Profession of Medicine” will continue to exist as an elective at Charité–Universitätsmedizin Berlin, with a new director and new students involved in the planning and teaching of the course. The course so far has reached more than 140 students in two years. It will continue to serve as a forum for learning about psychosocial, ethical and cultural issues, it will continue to provide an opportunity for international exchange among students and faculty, and it will continue to stimulate students and faculty to develop new ideas and initiatives in these important, still under-appreciated aspects of medical education.

Acknowledgements

The authors would like to thank Ulrike Arnold, Director of Charité International Cooperation at the Charité–Universitätsmedizin Berlin for her logistical support, Hannah Haumann, Katja Hess and Magdalena Stepien for their commitment and their help with the implementation of the course, and to Joachim Seybold, MD, MBA, for his participation and continued involvement and leadership.

Additional information

Notes on contributors

Regine Wood Tillmanns

REGINE WOOD TILLMANNS, MD, FACP, was Instructor of Medicine at Northwestern University's Feinberg School of Medicine, Chicago until October 2006. From 2004–2006, she was an international fellow in medical education at the Charité–Universitätsmedizin Berlin, Germany. She is now assistant professor at Texas Tech University Health Sciences Center at El Paso, Texas, USA.

Anna Ringwelski

ANNA RINGWELSKI, MD, graduated from Northwestern University's Feinberg School of Medicine, Chicago, USA, in 2006. She is currently completing a residency training program in Emergency Medicine at Bellevue Hospital/New York University in New York City, USA.

Johanna Kretschmann

JOHANNA KRETSCHMANN, MS, is a clinical psychologist at a Psychosomatic Clinic in Bernau, Germany. Until recently, she was a faculty member in the Department of General Medicine at the Charité–Universitätsmedizin Berlin, involved in program development and evaluation.

Luita D. Spangler

LUITA D. SPANGLER, PhD, received her doctorate in English Literature at the University of New Hampshire, USA. She currently teaches English at the Freie Universität Berlin and the Universität Potsdam, Germany.

Raymond H. Curry

RAYMOND H. CURRY, MD, FACP, is Professor of Medicine and Medical Education, and Executive Associate Dean for Education at Northwestern University Feinberg School of Medicine, Chicago, USA.