Zeitschrift fur arztliche Fortbildung最新文献

The introduction of the new German specialist for psychiatry and psychotherapy increased the requirement for more integrated and flexible clinical training programs for residents. The integration of this multitude of more sophisticated diagnostic and therapeutic strategies in an individualized treatment plan for each patient requires new teaching strategies. The instructional method "Cognitive Apprenticeship" in acquisition of treatment planning-competence is discussed within a curriculum framework.

Medical care for patients with cancer is in worldwide discussion about the therapeutic goals. Additionally to cancer therapy, pain therapy and symptom control is getting more and more attention. The definition of structural quality aspects, process quality and resulting quality provides a valuable tool for analyzing status and goals in cancer pain therapy. In this paper, we present a computerized documentation program which leads through pain analysis to initiation, evaluation and control of therapeutic results following WHO-guidelines. Information is offered during the documentation procedure. The program fills therapeutical (documentation) gaps during everyday practice concerning pain and symptom control in cancer patients. The program presents a kind of "on demand" continuing education.

Neither the HIV-specialists, the cooperating specialists, nor the family physicians are required to have special qualifications to treat HIV-infected patients. CME-courses don't consider the very different fields of interest of the participants or that the transfer of knowledge is quite important to ensure the quality of medical care. Questionnaires regarding HIV related topics were distributed in nine HIV-CME courses (9/93-5/94) of the DAGNA (German association of panel physicians treating HIV-infected patients) in cooperation with the society of physicians of Germany and the association of public health insurances. The satisfaction of the participants, the topics with regard to their relevance for the task group, the importance for the daily routine, and didactic manners were investigated. Feed-back: 41%. Although the general impression of most participants was "quite satisfying" (87%) there was some critic regarding special aspects. The rating of the courses depended on the level of qualification. Specialists in internal medicine rated the relevance for their medical practice, the topics and the possibility of contribution more positive than other specialists or general practitioners (GP). In general, there was a great difference regarding the rating of the courses among the participants because of their individual level of qualification and knowledge. In order to take the different levels of qualification and demands for topics into account there must be graduated courses: specialists, experts, elementary and beginner courses. The basic courses should contain not only the lectures but also the possibility of an active contribution of the participants. Adequate guidelines have to be developed.

The therapy of the alcohol withdrawal syndrome is very heterogeneous with more than 100 drug combinations. This results from differently qualified physicians and from insufficient pharmacostudies concerning evaluation and psychopathological methodology of the alcohol withdrawal syndrome. The following advices can be given: Physical withdrawal should take place under the conditions of an appropriate hospital with a qualified team. The application of electrolytes and vitamines (B1) may be necessary in alcohol addicts. Less severe alcohol withdrawal syndromes are treated sufficiently with carbamazepine, sometimes it can be necessary to combine it with neuroleptics or benzodiazepines. A secure prevention from delirium tremens and its treatment is only guaranteed by clomethiazole or benzodiazepines. To reduce the doses of those drugs, combinations with neuroleptics are possible. In general voluntary physical withdrawal proves only to be successful if longtime abstinence is planned and a motivation program is setup the for withdrawal treatment.

The controversial discussion about the use of methadone in the treatment of drug addicts has occupied specialists in West Germany for decades. Owing to the political pressure to find a solution to the drug problem, methadone has been an established place in the classical drug treatment system for a long time. Therefore, there has been a supplement (in 1991) to the guidelines of the N.U.B. that under special conditions, it is now possible, for a physician working in a practice or outpatient clinic to use methadone substitution as a routine procedure. The psychosocial care of the patient ist also very important in addition to the purely medical provision of a substitute drug which blocks the heroin hunger and helps prevent criminal activity. The profound dependence of a drug addict is not created primarily by the consumption of addictive substances but must be seen as the result of a severely disturbed personality development and treated accordingly. The individual context of the particular drug scene, scene behavior and jargon should also be taken into account. It is not sufficient to explain addiction and dependence by means of chemical formula or physiological processes. Thus, a substitution treatment always includes two crucial aspects: the soothing and protecting aspect of the medicine administered and the conflict and insight orientated aspect of the therapeutic commitment. The physician, the clinic employees and the social worker should be comprehensively and thoroughly qualified in order to deal with the equally wide-ranging demands of substitutions therapy.

In a representative national survey, general practitioners and psychiatrists were asked about their experience and knowledge with regard to psychological sequelae of traumatic life events. A questionnaire addressing 10 traumatic stress related issues was mailed to every fifth general practitioner and psychiatrist in private practice in Switzerland (N = 1284). The return rate was 37%. Every second doctor reported having experiences in treating posttraumatic disorders. Sexual abuse and accidents were the mostly mentioned traumas. General practitioners are frequently confronted with acute stress disorders, while psychiatrists more often have to deal with PTSD. Psychiatrists knew more about specific treatment possibilities than general practitioners. Only a minority was satisfied with the existing therapeutic services for trauma victims. Few doctors (more psychiatrists than GPs) had plans for further education. A majority suggested interdisciplinary treatment approaches. When planning further education, preference should be given to interdisciplinary approaches, taking into consideration at the same time the specific needs of different professional groups.

The therapy of drug addicts must not be confused with measures to reduce drug problems. Therapy means medical care for the treatment of a disease. In the treatment of drug addiction, we apply pharmacological and psychological therapy but also psychosocial techniques to address the problems of an addict. Actions might contain causal, symptomatic, or palliative therapies according to the measures currently available. The choice of a treatment procedure in the frame of the available alternatives is oriented on the objective findings, the chance for success, and the patient's intentions. The therapy of the drug addiction is divided into the stages of contact, detoxification, weaning, and aftercare. We aim for a patient's living without consuming drugs and the ability to critically and socially deal with the reality. The break with the pleasure/reluctance principle and switching to the performance principle is crucial. We have success rates ranging between 20 and 40% over five years in the currently available treatment-facility. The substitution therapy is also available as an additional choice for a smaller group of addicts where we do without an abstinence. Naturally, this is a substitution with methadone and may only be a measure for prolonging life. The application of heroine has currently no foundation as it has no advantages to the administration of methadone. Therefore, we should focus mainly on abstinence orientated procedures and to keep the methadone substitution ready for a small group resistant to therapy.

The potential risks of obtaining an HIV infection during the clinical routine becomes recently more and more a subject for discussion. The assessment of HIV transmission in the hospital by medical students seems to be important, because medical students are doing practical nursing training, medical clerkships and courses in the hospital, are in a developing process to their later social role as a physician and because of their age, they belong to the group with the highest statistical risk of getting HIV infected. The following study analysed the view of medical students to get HIV infected in typical clinical routine situations and non-clinical situations. 316 medical student in the first year (average age: 22 years, female = 171, male = 145) estimated the risk of getting HIV infected for 18 different clinical and non-clinical situations. The survey was done in 1991 and 1993. It becomes obvious, that medical students still have gaps in their knowledge about HIV transmission. Over 10% of them estimated non-clinical situations like mosquito- and animal-bites or clinical situations like changing dirty linen or physical examination as situations with a high risk of getting HIV infected. The study shows, that medical students need more informations and counselling about HIV related aspects for their later work as a physician.

Medical guidelines are an important part of quality control programs. They may act on knowledge, attitude, and behaviour of physicians as well as of medical laymen and, therefore, on the quality of medical care. As guidelines have been developed and distributed in the U.S. and in other countries for decades, recommendations for the medical practice termed "guidelines" or "consensus reports" are more and more distributed in Germany, as well. However, the internationally accepted quality criteria are only rarely taken into account for such independent guidelines. This review aims to impart such quality criteria. Additionally, a structure for a standardized review and organization of guidelines is proposed.

According to the author's experience with addiction diseases, questions of etiology, diagnostics, and therapy are reviewed. Starting with basic terms: such as the addicted human and his background, the drugs and the disease, chosen facts are combined with the author's individual experiences and theories for pragmatic actions are derived.