German Medical Association Research Articles

Editorial to the revision of the “Guideline of the German Medical Association on quality assurance in medical laboratory examinations – Rili-BAEK”

Editorial to the revision of the “Guideline of the German Medical Association on quality assurance in medical laboratory examinations – Rili-BAEK”

Sustainability-national and international initiatives in intensive care and emergency medicine

Climate change with global warming, natural disasters, species extinction and soil erosion is doubly relevant for medicine: On the one hand, heat waves, floods and other natural disasters lead to new disease patterns to which healthcare systems must adapt. On the other hand, the global healthcare system itself contributes to these effects, as it is estimated that the CO2 footprint of all healthcare facilities accounts for around 5% of global greenhouse gas emissions. National and international initiatives to promote sustainability concepts in intensive care and emergency medicine. Research on homepages of national and international (specialist) societies dealing with intensive and emergency care medicine and corresponding PubMed search (sustainability and climate change and emergency or intensive care medicine). Six of the 12national specialist societies surveyed have taken initiatives on sustainability, notable among them the initiative of Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF) for anew registration of the S1guideline "Sustainability in intensive care and emergency medicine". On the international scene, the activities of the Australian and New Zealand Intensive Care Society (ANZICS) with numerous publications on the topic of sustainability in intensive care medicine and the practical guide "Abeginners guide to sustainability in intensive care medicine" as well as the European Society of Anaesthesiology and Intensive Care (ESAIC) with aconsensus paper on sustainability should be highlighted. At the national level, initiatives on sustainability (guidelines, working groups, forums) are emerging and are attracting increasing attention and activity. The umbrella organization of German Intensive Care Medicine, the Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI), has so far shown no (discernible) activity; there is an urgent need for action here, and health policy and the German Medical Association should also become (even) more involved in reducing the CO2 footprint in the healthcare sector. Internationally, there are anumber of societies and institutions that are promoting the topic of "sustainability", although astronger focus on the area of intensive care and emergency medicine would also be desirable here.

Beyond the basics: Sigma scores in laboratory medicine with variable total allowable errors (TEa)

BackgroundTo diagnose diseases, track the effectiveness of treatments and make well-informed clinical decisions, doctors rely on results from laboratories. Accurate and precise results minimize the necessity for additional testing, saving time and money while enhancing patient satisfaction.. Internal quality control and an external quality assurance scheme(EQAS) are metrics used to evaluate a clinical laboratory’s performance. One of the numerous quality indicators that can be used to gauge the amount of errors is sigma metrics. To calculate the sigma scores bias%, CV%, and Total Error Allowable (TEa) are needed. Total Error allowable(TEa) is a crucial benchmark that establishes allowed limits on the degree of deviation from the target value for a certain analyte. Nevertheless, a proper consensus for establishing a TEa goal has not been reached and the impact of this limiting factor in standard laboratory practice and sigma calculation has not been sufficiently established. Choosing the right Total Error allowable(TEa) goal is one of the greatest challenges when employing sigma metrics as depending on the source, several measurands of TEa values may exhibit alteration. Material and methodsOur study aims to determine the sigma scores of 20 routine chemistry parameters using six different TEa sources: Clinical Laboratory Improvement Amendment (CLIA 88′), CLIA(Clinical Laboratory Improvement Amendment) 24, BDV (Biological Variation Desirable), RCPA(Royal College of Pathologists of Australasia), RiliBak(Guideline of the German Medical Association for Quality Assurance of Laboratory Medical Examinations), and EMC/Spain(Measurement and Control Scheme) over a 12-month period using the bias percent from the External Quality Assessment Scheme (EQAS) and coefficient of variation (CV) from the Internal Quality Control (IQC). Detection system was automated, multi-channel, selective analyzer, the Beckman Coulter AU680 which works on the principle of spectrophotometry. To compute the Sigma metrics, formula used was Sigma = (TEa – Bias%) / CV%. By comparing the sigma values from the different TEa sources, TEa variance on the evaluation of the sigma metric was ascertained after which an internal quality control plan and QGI(Quality Goal Index) for underperforming parameters were devised. ResultsThe study discovered that the sigma values of common chemical parameters varied significantly based on the TEa sources used. Maximum parameters in the above three-sigma zone were TBil, HDL, CK, ALP, amylase and uric acid in CLIA’88 while RCPA and Biological variation were determined to be the most severe, with the highest performing parameters falling below three sigma zones. Rilibaek was the most liberal, with only sodium in the lower three sigma zones along with CLIA’88. The findings indicate that there is the substantial influence of various Total Error Allowable (TEa) sources on the sigma metric evaluation. A quality control plan was devised depending on different sigma scores of the analytes using biorad unity 2.0 software(westgard sigma multirules). The origins of errors that resulted in low sigma ratings liked enhanced cleaning of electrodes, electrode replacement, ageing of reagents, instrument maintainence were pinpointed and addressed. ConclusionThe study highlights the necessity of harmonizing and standardizing sigma metrics, stressing the significance of choosing suitable total error allowable goals (TEa). The creation of worldwide standards and recommendations for total error allowable (TEa) can lead to its harmonization. Establishing a consensus on the acceptable levels of error for various laboratory tests would necessitate the cooperation of specialists from many nations and organizations in order to set such guidelines and standards.

Updated analysis of the prescription and evaluation of protein kinase inhibitors for oncology in Germany.

A recent analysis from our group ( https://pubmed.ncbi.nlm.nih.gov/37014400/ ) has shown that the immense costs of the 20 protein kinase inhibitors for oncology approved from 2015 to 2019 are largely caused by drugs whose additional benefit has not been proven. We updated our analysis by adding the newly approved protein kinase inhibitors of the years 2020 and 2021. Based on the 2021 and 2022 Arzneiverordnungsreport (AVR), we expanded our analysis to include a total of nine protein kinase inhibitors newly approved by the European Medicines Agency (EMA) in 2020 and 2021. As a result, 29 protein kinase inhibitors were identified for an update of our analysis. For these 29 drugs, all additional benefit assessments published by the Gemeinsamer Bundesausschuss (GBA) were analyzed. The additional benefit assessments of the GBA were compared with the corresponding assessments of the European Society for Medical Oncology (ESMO), the Deutsche Gesellschaft für Hämatologie und Onkologie (DGHO, German Society for Hematology and Oncology) and the Arzneimittelkommission der deutschen Ärzteschaft (AkdÄ, Drug Commission of the German Medical Association). In addition, a total number of 91 drug advertisements published in the journal Oncology Research and Treatment in 2022 were analyzed. The number of protein kinase inhibitors for which no additional benefit can be found by the GBA is increasing, whereas the number of drugs for which a considerable additional benefit can be found is decreasing. Thus, in the current 2022 (re)assessment of additional benefit by the GBA, no additional benefit was identified for 50% of the drugs (2020, 46%). Nineteen percent were assessed with a minor additional benefit (2020, 18%) and also 19% with a considerable additional benefit (2020, 27%). For 12% of the drugs, the additional benefit could not be quantified by the GBA (2020, 9%). The benefit assessments by other medical societies often differ significantly from those of the GBA, mainly due to different evaluations of various endpoint parameters. In addition, more and more protein kinase inhibitors are being approved as orphan drugs. However, their additional benefit cannot be quantified by the GBA in most cases (78%). In 38% of the advertisements of an oncology journal, protein kinase inhibitors are promoted, which shows the pharmacoeconomic importance of these drugs. In summary, the current additional benefit assessment procedure in Germany is very questionable, and reforms are urgently needed to maintain the stability of the German healthcare system, which is being undermined by the high cost of medicines, particularly for drugs whose additional benefits have not been proven.

Does the Innovation Fund Improve Healthcare Provision? A Critical Assessment of the Status of Implementing Successful Innovation Fund Projects into Healthcare Practice

Since 2015, the Federal Joint Committee (G-BA)'s Innovation Fund has been supporting projects in health services research and new health service models ("Neue Versorgungsformen", NVF). By the end of 2022, 211 projects in the NVF category had been funded. A key objective is the transfer of successful projects into standard care. This article analyzes previous projects regarding their incorporation into routine care based on transfer recommendations of the Innovation Fund Committee ("Innovationsausschuss" IA). Descriptive analysis of all projects completed by August 1, 2023 with transfer recommendations in the "NVF" funding stream. Presentation by topic, project duration, time until IA transfer decision, categorization, and number of institutions and organizations (recipients) addressed per project, their feedback published on the G-BA website, response rates per recipient group, and a content classification and interpretation of exemplary feedback. Recommendations based on the results and their discussion in an expert workshop. Out of 57 NVF projects, 17 had a transfer recommendation. A total of 57 feedback responses were received from a total of 431 recipients addressed by the IA across these projects. Response rates varied significantly. One-third of inquiries to the G-BA and its member organizations received a response (31%), while only every fifth inquiry to federal states (18%) and professional societies (18%) got a response. Less than one in ten inquiries to the Federal Ministry of Health (8%), administrative bodies (6%), and the German Medical Association (0%) received a response. Project-specific feedback within a recipient group was often contradictory or limited to regional scope. The transfer process reveals significant structural and procedural obstacles regarding the incorporation of projects evaluated as successful into routine health care. To ensure that funding from the innovation fund is most effectively used, there needs to be a realistic chance of successful transfer of positive project outcomes into routine care. The DNVF recommends stronger involvement of rule-competent institutions, mandatory publication of responses, structured moderation of the transfer process, expanding types of selective contracts, financing of implementation phases and of studies drawing on results across successful NVF projects.

Brain death diagnostics: use of ancillary tests

AbstractWith the determination of the definitive, irreversible loss of the overall function of the cerebrum, cerebellum and brain stem (irreversible loss of brain function, IHA, "brain death"), the death of the human being is determined from a scientific-medical point of view. The determination of IHA, with cardiovascular function being maintained by intensive care, requires special diagnostics ("brain death diagnostics"). This is carried out in the intensive care unit either to assess the medical prognosis, or as a prerequisite for post-mortem organ donation. In Germany, in accordance with the Transplantation Act, the procedural rules for determining IHA are laid down in corresponding guidelines of the German Medical Association (RL-BÄK), the 5th update of which has been in force since September 2022. Here, the indications, the requirements and the technical procedures of ancillary tests (electroencephalography, early auditory and somatosensory evoked potentials, Doppler and duplex sonography, computed tomography angiography, radionuclide perfusion scintigraphy, digital subtraction angiography) according to the German guidelines are outlined.

Clinical acute and emergency medicine curriculum-focus on internal medicine : Recommendations for advanced training in internal medicine in the emergency department

In Germany, physicians qualify for emergency medicine by combining aspecialty medical training-e.g. internal medicine-with advanced training in emergency medicine according to the statutes of the State Chambers of Physicians largely based upon the Guideline Regulations on Specialty Training of the German Medical Association. Internal medicine and their associated subspecialities represent an important column of emergency medicine. For the internal medicine aspects of emergency medicine, this curriculum presents an overview of knowledge, skills (competence levels I-III) as well as behaviours and attitudes allowing for the best treatment of patients. These include general aspects (structure and process quality, primary diagnostics and therapy as well as indication for subsequent treatment; resuscitation room management; diagnostics and monitoring; general therapeutic measures; hygiene measures; and pharmacotherapy) and also specific aspects concerning angiology, endocrinology, diabetology and metabolism, gastroenterology, geriatric medicine, hematology and oncology, infectiology, cardiology, nephrology, palliative care, pneumology, rheumatology and toxicology. Publications focussing on contents of advanced training are quoted in order to support this concept. The curriculum has primarily been written for internists for their advanced emergency training, but it may generally show practising emergency physicians the broad spectrum of internal medicine diseases or comorbidities presented by patients attending the emergency department.

Longitudinal analysis of external quality assessment of immunoassay-based steroid hormone measurement indicates potential for improvement in standardization.

As hormonal disorders are linked to several diseases, the accurate quantitation of steroid hormone levels in serum is crucial in order to provide patients with a reliable diagnosis. Mass spectrometry-based methods are regarded as having the highest level of specificity and sensitivity. However, immunoassays are more commonly used in routine diagnostics to measure steroid levels as they are more cost effective and straightforward to conduct. This study analyzes the external quality assessment results for the measurement of testosterone, progesterone and 17β-estradiol in serum using immunoassays between early 2020 and May 2022. As reference measurement procedures are available for the three steroid hormones, the manufacturer-specific biases were normalized to the reference measurement values. The manufacturer-specific coefficients of variation were predominantly inconspicuous, below 20% for the three hormones when outliers are disregarded, however there were large differences between the various manufacturer collectives. For some collectives, the median bias to the respective reference measurement value was repeatedly greater than ±35%, which is the acceptance limit defined by the German Medical Association. In the case of testosterone and progesterone determination, some collectives tended to consistently over- or underestimate analyte concentrations compared to the reference measurement value, however, for 17β-estradiol determination, both positive and negative biases were observed. This insufficient level of accuracy suggests that cross-reactivity continues to be a fundamental challenge when antibody detection is used to quantify steroids with a high structural similarity. Distinct improvements in standardization are required to provide accurate analysis and thus, reliable clinical interpretations. The increased accuracy of the AX immunoassay for testosterone measurement, as observed in the INSTAND EQAs between 2020 and 2022, could be the result of a recalibration of the assay and raises hope for further improvement of standardization of immunoassay-based steroid hormone analyses in the coming years.

Prevention of Artificial Intelligence (AI) Misuse in Online Medical Education

Aim: This study aims to assess the capabilities of artificial intelligence (AI) in answering online Continuing Medical Education (CME) courses to find the resistant to AI-misuse strategies. Materials and Methods: The study evaluated 30 CME online courses from popular American (ACCME), European (EACCME), and German Medical Association accredited online platforms, including Medscape, eaccme.uems.eu, Springer Nature, der-niedergelassene-arzt, and Aerzteblatt. ChatGPT Version 4.0 with integrated plugins for interactive AI chats with documents, web access to scientific databases, and interactive AI chats with videos was used to answer the CME evaluation questions. A special scoring system, referred to as "complexity score," was introduced in the study. This system has two main objectives: first, to assess strategies that prevent the misuse of AI in medical online education; second, to measure the effort that physicians must invest to answer CME questions using AI. Results: AI was used to answer a total of 248 questions, divided into three categories: ACCME accredited courses: 7 credits; EACCME accredited courses: 9.5 credits; German CME courses: 28 credits. AI successfully completed the quiz in 90% of cases (27 courses) and showed an accuracy rate of 86%. 213 out of 248 questions were correctly answered: 38 out of 48 ACCME questions; 85 out of 100 EACCME questions; 90 out of 100 CME questions. The outcome "AI error" was significantly associated only with a higher number of questions in the quiz: p-value 0.01. However, this predictor had no impact on the AI's ability to successfully complete the entire quiz. The AI failure rate was significantly associated with learning materials based on new studies without open access: p-value 0.02 and the need to view all learning materials to gain access to the quiz: p-value 0.02. A higher complexity score of the course was significantly associated with AI failure rates: p-value 0.0034. Conclusion: This study has shown that AI can successfully answer medical quiz questions even without access to learning materials. Therefore, the best strategy to prevent the misuse of AI in CME online training is to align human learning with AI feeding. Access to the quiz should only be possible after a complete review of the learning materials. This could be achieved by setting a fixed time or through multiple slides with separate access to each slide and subsequent quiz access.

Determinants of implementing the ID ROLL OUT study's interventions: qualitative results

Abstract Issue Antimicrobial stewardship programmes (ASP) and infectious disease (ID) specialists aim to ensure the rational use of antimicrobials and to improve patient outcomes. Whilst ASPs are established to varying degrees, ID specialists are rarely available in secondary and tertiary care hospitals in Germany. Description of the problem With the ID ROLL OUT study, we implemented and evaluated an intervention, which comprises ASP with and without ID specialists’ consultation in ten hospitals (excl. university hospitals) in south-west Germany. Little has been reported on the medical and pharmaceutical staff's perspectives on the implementations. This study describes barriers, facilitators, and suggestions for improvement to successfully establish a large-scale multicentre intervention. The participants responsible for implementing the intervention were interviewed using semi-structured, guided interviews at two time-points (t1: n = 17; t2: n = 18). The recorded interviews were analysed for content, following Kuckartz. Results A high level of acceptance and a positive attitude towards the intervention are conducive to the intervention's successful implementation. The teams find extra time for the study and a close staff collaboration at a local team level to be helpful. The main barriers identified are a high workload, lack of acceptance by colleagues in key roles, and the Covid-19 pandemic. Lack of digitalisation and entrenched internal structures were identified as major barriers. To further improve implementation, more infectious disease training should be provided, along with support from superiors and extension of the intervention phase. Moreover, government-mandated ASP guidelines and quality management by the German Medical Association are desired and expected to contribute in the future. Lessons The identified determinants provide much-needed key information, which is important for the efficient, targeted and successful implementation of future similar interventions. Key messages • Acceptance, positive attitude and staff collaboration help to implement the intervention. • Heavy workloads and lack of support from key colleagues hinder the intervention’s implementation.

Awards in pathology-aman's world?

Awards provide their recipients with fame and recognition, and subsequently facilitate publications and acquisition of external funding through increased visibility. We hypothesize that despite increasing representation in pathology, women are underrepresented as awardees in the German Society of Pathology and consequently there is an associated imbalance between genders. Published data from the German Society of Pathology on female awardees during the period from 2000 to 2022 were examined. Only awards specifically dedicated to the field of pathology were considered. In addition, the publicly available data of the German Medical Association on gender and age distribution of pathologists in Germany were considered as reference material. Atotal of six different awards were included in the analysis. Among the 143 awardees across 150 individual awards in the period from 2000 to 2022, 55(38.4%) of the awardees were female compared to an average percentage of 31% of women working in the field of pathology in the 23-year period under consideration. Consequently, female awardees in pathology were not underrepresented when compared to the national figures on the proportion of women in the field of pathology. However, the distribution of female awardees across individual awards suggests that women were increasingly represented in less prestigious research and doctoral awards, while men made up alarge proportion of awardees of honorary awards (0% women) and prestigious awards (17% women).

Diagnosis of brain death in Germany-Implementation of the guidelines of the German Medical Association

The 4th update of the guidelines of the German Medical Association on the diagnosis of irreversible loss of brain function (brain death, BD) has introduced important new regulations regarding the required qualification of the examiners, approved procedures for ancillary testing, and aclarification regarding the sequencing of diagnostic steps. Investigation of the implementation and practical effects on the diagnosis of brain death. Descriptive evaluation of the routine documentation of the German Organ Procurement Organization, comparing the periods July 2011-June 2015 (3rd update) and July 2015-June 2019 (4th update). Patient numbers decreased from 6100 to 5403. The largest decrease affected hospitals without neurosurgery. Children were not affected. With the 4th update, clinical diagnostics were increasingly performed during on-call hours by external neurologists. Of the patients 83.8% now received ancillary tests compared to 80.1% previously. Computed tomography angiography (CTA), first introduced in the 4th update, was applied in 23.2% and established complete loss of cerebral circulation in 89.4%. The time between first documentation of the clinical signs of BD and certification of BD increased from 7.0 ± 12.7 h to 8.2 ± 14.2 h. The diagnosis was slightly less frequent with 95.3% compared to 96.6%. The updated standards were implemented in accordance with the guidelines. The demand for external consulting neurologists and neurosurgeons as well as the time required for BD assessment have increased. Negative effects on pediatric BD diagnostics were not apparent. CTA is widely and successfully used in adults as anew ancillary diagnostic procedure.

End-of-Life Care: medical and therapeutic aspects

According to data from the German Federal Statistical Office, 424635 patients died in hospitals across Germany in 2020. That is 43% of all deaths. Deaths occur everywhere in hospitals - not just in palliative care units - and caring for the dying is considered a basic task of medical practice 1. The German Medical Association has published principles for end-of-life care and the S3 guideline on palliative medicine also provides instructions on what end-of-life care should look like. However, there is often uncertainty as to what the care of the dying should look like in concrete terms. The following explanations are intended to convey how ideal end-of-life care should be designed and provide concrete assistance and suggestions as to how this can also succeed outside a palliative care unit.

50 years of the first ethics commission in Germany: the Ulm Ethics Commission in an international perspective.

The creation of the legal framework to recognize rights of patients and participants in clinical trials began in Germany in the 19th century. However, the ethical review of medical research in terms of the protection of rights and welfare of human subjects has only become a widespread practice since the establishment of ethics commissions. The first ethics commissions emerged at the universities under the influence of the German Research Foundation. The widespread establishment of ethics commissions began in the Federal Republic of Germany in 1979, after the adoption of the recommendation of the German Medical Association for the establishment of ethics commissions. We analyzed unpublished archival documentation of the Ethics Commission of the University of Ulm and evaluated it based on a thorough review of research works on the history of international and German ethics commissions. For the examination of the sources, we implemented the historical-critical method. The first ethics commission in Germany was set up at the University of Ulm in 1971/72. The reason for that was that the German Research Foundation required grant applications for medical research involving human subjects to be reviewed by an ethics commission. Initially the commission was created at the Center for Internal Medicine and Pediatrics, its authority grew over time until in 1995 it became the central Ethics Commission for the entire University of Ulm. Before the adoption of the Tokyo revision of the Declaration of Helsinki in 1975, the Ulm Ethics Commission developed its own guidelines for the conduct of scientific investigations on humans based on international ethical principles. The Ethics Commission of the University of Ulm must have been established between July 1971 and February 1972. The German Research Foundation played a decisive role in the establishment of the first ethics commissions in Germany. The Universities had to create ethics commissions in order to be able to obtain additional funds from the Foundation for their research. Thus, the Foundation initiated the institutionalization of the ethics commissions in the early 1970s. The functions and composition of the Ulm Ethics Commission were similar to other initial ethics commissions of the time.

Longitudinal Evaluation of AFP and CEA External Proficiency Testing Reveals Need for Method Harmonization.

The glycoproteins alpha-fetoprotein (AFP) and carcinoembryonic antigen (CEA) have long been approved as biomarkers for diagnosing and monitoring tumors. International Reference Preparations (IRPs) have been around since 1975. Nevertheless, manufacturer-dependent differences have been reported, indicating a lack of harmonization. This paper analyzes data from 15 external quality assessment (EQA) surveys conducted worldwide between 2018 and 2022. The aim was to gain insight into the longitudinal development of manufacturer-dependent differences for CEA and AFP. In each survey, participating laboratories received two samples with different tumor marker levels. Inter- and intra-assay variability was analyzed and the mean 80% and 90% of the manufacturer collectives were compared to the evaluation criteria of the German Medical Association (RiliBÄK). The median EQA results for CEA revealed manufacturer-dependent differences between the highest and lowest collective of up to 100%; for AFP, the median differences mostly remained below 40%. The coefficients of variation were predominantly low for both markers. We concluded that the current assays for AFP and CEA detection are better harmonized than previously reported. The assays displayed a good robustness; however, a narrowing of the current assessment limits in EQA schemes could further enhance the quality of laboratory testing.

Empfehlungen der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Hals-Chirurgie (DGHNO-KHC) für die Erteilung der fachspezifischen Weiterbildungsbefugnis

The 2018 template for otorhinolaryngology specialist training of the German Medical Association is increasingly implemented by the federal associations. In this regard, the German Society recommended an otorhinolaryngology resident training plan for Otorhinolaryngology, Head and Neck Surgery (DGHNO-KHC) together with the Professional Association of German Otorhinolaryngologists as a suggested guideline for the federal medical associations. In this context, the state medical associations currently work on criteria on the basis of which otorhinolaryngologists and their training institutions can be granted authority for such a certified otorhinolaryngology resident training program.The DGHNO-KHC last made recommendations for the granting of authorizations for specialist training in otorhinolaryngology in 1999. Many contents have changed as a result of the 2018 model specialist training regulations. Therefore, a scientifically formulated proposal for the granting of continuing education authorizations is herewith provided as recommendation to the federal state medical associations.

Who is sensitising whom? A participatory interview guide development as an awareness tool within a health care research project

Who is sensitising whom? A participatory interview guide development as an awareness tool within a health care research project

The state of infectious disease training in Germany before introduction of the new board certification in internal medicine and infectious diseases: past experience and future expectations

PurposeRecently, the German Medical Association introduced a new board certification in Internal Medicine and Infectious Diseases (ID). Accompanying, current experience with ID training and expectations for the new curriculum were assessed.MethodsAfter the development of a digital survey covering four main areas with 59 questions, it was distributed via the German Society for Infectious Diseases (DGI) and other networks following a snowball principle. Participation was carried out digitally in a web-based application.ResultsBetween December 2021 and February 2022, 300 datasets were included. 38.9% (114/293) of respondents had completed the additional training in ID. Of those, 54.0% (61/113) were concerned about recognition of previous training certification in the future after the establishment of the new sub-specialization. Overall, 78.5% (135/172) of respondents were satisfied or rather satisfied with the qualification gained through their training, but 8.7% (15/172) felt poorly prepared by their ID training. With regard to the inclusion of microbiology or antimicrobial stewardship (AMS) training into the new ID training curriculum, 84.6% (254/300) and 87.7% (263/300) of participants, respectively, desired an integration. Only 30.8% (53/172) felt sufficiently supported by their employer regarding childcare and 51.7% (89/172) reported missing support for scientific commitment.ConclusionOverall, ID training in Germany seems satisfactory so far, but there is uncertainty about future recognition. Participants find that AMS and microbiology training should be integrated into new ID training curricula. New concepts regarding the compatibility of childcare and career as well as the support of scientific commitment seem essential to attract young professionals to the field.

Social media, are they necessary?

Many areas of medicine are already doing it, but cardiac surgery in Germany is still very reluctant. We are talking about social media. Digital platforms are increasingly becoming useful tools in everyday life, for example when it comes to patient education and continuing medical education. The visibility of your own paper can also be increased many times over in avery short time. In addition to the positive effects, there are also negative effects. To ensure that the benefits outweigh the negative aspects and that every doctor knows what he or she must adhere to, the German Medical Association has defined clear rules. Use it or lose it.

Structure of outpatient urology care in Germany

Although urological specialist practices are central pillars of outpatient care, there is alack of current data on the care structure of these practices. Adescription of the structures in large cities versus rural areas as well as gender effects and generational differences is needed not only as abaseline measure for further studies. The survey includes data from the physician directory of the Stiftung Gesundheit as well as from the German Medical Association and the Federal Statistical Office. Colleagues were divided into subgroups. Based on the different subgroup sizes, statements about the care structure of outpatient urology in Germany can be made. While the majority of urologists in larger cities work in professional practice groups and care for fewer patients on average, in rural areas there is aparticularly high proportion of individual practices with more inhabitants to be cared for per urologist. Female urologists work more frequently in the context of inpatient care. When female urology specialists choose to establish themselves, they are more likely to do so in practice groups and in urban areas. In addition, there is ashift in gender distribution: the younger the age subgroup considered, the higher the proportion of female urologists among all colleagues. This study is the first to describe the current structure of outpatient urology care in Germany. Future trends are already emerging that will significantly influence our way of working and the care of patients in the coming years.