Zeitschrift fur arztliche Fortbildung最新文献

The question, whether evaluation of continuing medical education (CME) is necessary, is discussed in Germany for several years. It is frequently criticized that the effects of continuing education on the medical practice and the quality of the patient care are hardly concrete. Evaluation is too often understood as a tool of external control rather than an instrument of self control and feedback for the teachers and organizers of CME events. The evaluation methods in use have many methodological shortcomings, i.e., lack of objectivity, reproducibility, feed back to the students, nearness to practice, and are therefore reason for the missing acceptance of the evaluation by physicians. Evaluation methods make sense if they contribute to efficient learning. They are supposed to aid in correctly assessing both the need and success of learning. These demands are currently most completely fulfilled by the Canadian "Maintenance of Competence Program" (MOCOMP), the applicability of MOCOMP in Germany is now proofed by the German chamber of physicians.

Problems are frequently encountered regarding the terminology, diagnosis, differential diagnosis, and therapy of diseases of thes tendons insertion point (enthesis): Terms such as tendinosis, tenopathy, tendinitis, tendovaginitis, tendoperiostitis, insertions tenopathy, tendomyosis, etc. often are used interchangeably even through they describe anatomically and pathophysiologically different conditions. The term enthesiopathy is used as a generic term in this overview article irrespective of the causality.

Quality circles (peer review) will play an increasing and important role in ambulatory care when they are based on voluntary participation and in a setting of open discussion. Goal is the further qualification of physicians by critical reflections on their practice based on learning processes and the experiences of the participants. Reported are experiences from the unit for primary care and health service research of the Hamburg University on implementing quality circles. Engagement in quality assurance may be helpful in the shaping and professionalisation of general practice.

Back pain is a wide-spread complaint in modern society and in part an adverse effect resulting from present-day lifestyles. To date, too little attention has been drawn to efficient prevention. The treatment of patients affected with back pain today calls for an in-depth pathophysiological knowledge about the mechanism occurring on the spine. Diagnostic methods and non-operative treatment have been complemented specifically by chirotherapeutic methods. A systematic classification of the vertebragenous pain syndromes and the related treatment strategies have proven to be successful. Irrespectively of that, the individuality of diagnosis and the complaint's progress in each patient should be taken into account at all events. Cost-intensive diagnostic imaging should only be undertaken with a clear indication. Today, the overwhelming majority of back pain patients undergo a non-operative treatment. In case the conservative applications prove inefficient, it is possible to successfully operate on patients a with disc prolaps, degenerative instabilities as well as osseous spinal foraminal stenoses. A precondition is a precise causal diagnosis and a clear indication for operative intervention.

Clinical prevention is defined as the application of all individual practice contacts of patients and physicians during the screening after risky habits or living conditions for the following specific consultation (i.e., aiming for "free of tobacco") and/or induction of specific interventions (i.e., medical check-up, health examination, immunization). All data available up to now are demonstrating that the theoretically accessible options for clinical prevention are realized merely imperfectly by physicians and/or are hardly accepted by the patients. This may be due to the restricted perception and clarification of three problem areas; they are separately discussed: 1. The clinical prevention is also part of a comprehensive "prevention politic" and needs adequate general conditions. I.e., it is generally unclear, who is supposed to take care of the health promotion and prevention: the government with its public health services, the health insurances, the society of panel physicians? 2. Clinical prevention is more distant to a strict outcome orientation than other medical areas. There is a lack of a firm proof of its individual, epidemiological, cultural, and economical effects - namely the positive and negative ones. 3. (Clinical) prevention is especially exposed to ethical tensions. The protection of the patient's (or the client's) autonomy plays a particular role. If it is possible 1. to reduce the fear of physicians and patients for the political implications of clinical and medical prevention more than in the past, 2. to work out and distribute convincing empirical proofs of the desired (and undesired) effects of prevention, and 3. to discuss the ethical tensions typical of prevention as well as to reduce them in each single case, the program of clinical prevention would have a real chance in Germany. Otherwise it has to be feared that there will only be "Medical Prevention Weeks".

Especially regarding two respects, the psychiatric expert assessment differs from the expert assessment of other medical specialties: (1) No laboratory tests or technical equipment are available for the psychiatrist except for mental disturbances due to physical impacts such as brain injuries or intoxications. The psychiatrist depends on a carefully compiled case history and a differentiated psychodiagnostic. This may lead to a wrong assessment due to a lack of objectiveness. (2) There are a lot of legal areas where only the psychiatric or psychological expert opinion is required: i.e., the question of criminal responsibility during a trial, the assessment of legal capacity and the capability to will, for decisions about the custody of children etc. This is demonstrated with some cases as an example.

The subjects of psychiatric assessments do vary greatly. The main subject of criminal proceedings seems to be that of criminal responsibility. This leads to many misunderstandings. Court and expert have to use the same definitions. Criminal responsibility cannot be the deterministically interpreted freedom of will. The prevailing law does only answer insufficiently the question of selection or consultation of further experts.

This paper gives an overview over the basics and fundamentals of the medical expert assessment during civil action. Beginning with the character of the expert assessment as evidence in a lawsuit, the task distribution between physician and judges is discussed: Physicians are knowledgeable advisors, judges decide and determine direction and subject of the discussion and get the evidence necessary for them. The goal of the medical expert assessment is not treatment but guide the development of a decision about contentious claims. An offense against the evidence "assessment' during a lawsuit sometimes becomes a personal offense against the expert witness himself Regarding his response, he has to take into account that the expert witness as well as the judge may be refused due to bias, and to avoid the impression of prejudice especially in cases of medical liability. The appointed expert is always the expert witness independent of drafts by senior physicians or assistance by residents. Many civil lawsuits might not be decided without the teamwork between judges and physicians.

The standard for the assessment of the medical expert opinion is defined by the high demands expected from the judgement of a high court: Objectiveness, solid knowledge, self-criticism, in contestability in diction and firmness in the argumentation. From the legal point of view, the knowledge of the medical expert witness has to clearly go beyond the knowledge of his profession. The obligation for objectiveness is the basis of expert witness' activity. From the medical point of view, the physician has to take into account during the preparation of his expert assessment that structural deficiency of the personnel and surgical equipment of a department for surgery frequently plays a role due to the development of surgery to high tech medicine and the hospital physician cannot affect this. It is necessary for a physician as an expert witness to have basic knowledge about the evidence law and the medical liability process. On the other hand, judges and lawyers should basically know the medical way of thinking.

When an expert assessment for health reasons is carried out against a social welfare insurer, the medical expert has to know that he does not decide the outcome of the lawsuit. His task is to solely demonstrate and explain the medical facts. The lawyer decides whether this is followed by the claimed social contributions. It is not sufficient to just make a diagnosis. It has to be demonstrated what kind of consequences, i.e. whether a loss of functions or abilities occur and whether, therefore, impairments for the professional life can be derived. The area of conflict, where the expert witness moves between patient and medicine, legislation and client, becomes clear at the same time and is explained individually.