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Background Empathy plays an important role in the interaction and communication with patients. Physicians’ empathy has various positive patients’ and physicians’ outcomes. Despite the inclusion of empathy in medical curricula and the relevance of empathy in general and physicians’ concept of it to medical care, there is no common definition of empathy in the clinical context: definitions tend to be abstract and we do not know enough about medical students’ conceptualization of clinical empathy. A clear and consensual definition of empathy is needed to be able to teach and measure empathy adequately. We aimed to explore German medical students’ views and understanding of (clinical) empathy. Methods We interviewed 24 students from the second half of the 3rd year and in their final clinical year (six female and male students in each subgroup) using a semi-structured interview guide. Interviews were digitally recorded and transcribed verbatim. We analysed the transcripts using thematic synthesis (Braun & Clarke). Results We found three overarching themes: (1) empathy means perceiving and understanding patients’ needs and acting accordingly, (2) empathy as an interpersonal, intangible construct and (3) taking time for patients. Showing interests, impartiality and openness towards the patients as well as the need to take patients seriously, treating them with respect, having a holistic view on patients and generate some kind of closeness with patients are subthemes of the first overarching theme. Conclusions Although it is often stated that the various existing definitions of empathy are abstract or far from practice, German medical students seem to have a good idea how to define empathy. Their definition resembles definitions known from the literature and used in education. Further research is needed to compare concepts of empathy of medical students from different countries and cultural backgrounds to inform research and teaching. It would also be interesting to investigate how concepts of empathy change over the course of study and affect perceptions of empathy in third party assessments.

Background Somatic symptom disorder (SSD) is the successor diagnosis of somatoform disorder in the 5th Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Relevance and frequency of SSD and its clinical symptoms in general practice are still unknown. We estimate frequencies of patients fulfilling the diagnostic criteria of SSD in general practice. Methods Mailed and online survey with general practitioners (GP) in Germany using a cross-sectional representative sample from registries of statutory health insurance physicians. GPs estimated percentages of their patients who show the clinical symptoms of SSD according to DSM-5; that is, one or more burdensome somatic symptoms (A criterion), excessive symptom- or illness-related concern, anxiety, or behaviour (B criterion), and persistence of the symptoms over at least 6 months (C criterion). Statistical analysis used means and confidence intervals of estimated patient proportions showing SSD symptoms. Frequency of full-blown SSD was based on the products of these proportions calculated for each GP. Results Responses from 1728 GPs were obtained. GPs saw the clinical symptoms of SSD fulfilled (A and B criteria) in 21.5% (95% CI: 20.6 to 22.3) of their patients. They further estimated that in 24.3% (95% CI: 23.3 to 25.2) of patients, symptoms would persist, yielding a total of 7.7% (95% CI: 7.1 to 8.4) of patients to have a full-blown SSD. Conclusions We estimate a frequency of 7.7% of patients in general practice to fulfil the diagnostic criteria of SSD. This number may figure as a reference for the yet to be uncovered prevalence of SSD and it indicates a high clinical relevance of the clinical symptoms of SSD in general practice. Registration German Clinical Trials Register (Deutschen Register Klinischer Studien, DRKS). DRKS-ID: DRKS00012942. The date the study was registered: October 2nd 2017. The date the first participant was enrolled: February 9th 2018.

Background: Primary care plays a key role in pandemics like the SARS-CoV-2 pandemic in 2020. We aimed to investigate the challenges faced and the solutions implemented in primary care. Methods: One hundred and twenty-one general practitioners in Germany completed the online survey. We used open questions to examine challenges experienced and solutions implemented during the early pandemic and chose qualitative content analysis to extract and describe the meaning of the answers. We derived deductive categories from the research questions and formed inductive categories during the material reviews. Results: Main challenges were: insufficient information, lack of protective equipment, need to restructure practice procedures and insufficient individual and structural pandemic preparedness, resulting in secondary challenges: fear of infection, impaired patient care, aggravated steering of patients, difficult cooperation with external entities and a not viable hygiene concept advised by authorities. Strategies to address these challenges included establishing regular team-meetings to develop new solutions, focusing on few reliable sources of information, working in alternating shifts, increasing telemedicine, establishing window and open-air practices and building networks with other health care providers. Respondents criticized the lack of consideration of their experiences in planning pandemic measures within primary care. Conclusions: General practitioners successfully applied pragmatic and creative strategies in their practices during the early phase of the pandemic. Among these, communication within and between practices emerged as a key strategy. These strategies should be provided with pandemic preparedness plans. The lacking consideration of the primary care providers' experiences in planning and implementing pandemic measures needs to be addressed by stakeholders.

ObjectiveThis study aims to evaluate the usage and implementation of video remote (VR) interpreting and telephone remote (TR) interpreting in primary healthcare settings.DesignThis publication forms part of a larger three-pronged study in which we compared both remote interpreting modalities to each other and to a control group. This paper conveys the findings of the qualitative evaluation of the implementation and usage of both remote interpreting solutions. The quantitative evaluation of the 6-month intervention period (September 2018–February 2019) has been reported previously. After this period, we conducted focus groups with the healthcare professionals involved. The focus groups were recorded, transcribed verbatim and analysed using the structured qualitative content analysis.SettingWe provided either VR or TR tools to 10 different primary healthcare practices (general medicine, gynaecology and paediatrics) in the city of Hamburg, Germany.ParticipantsThree physicians and two physician’s assistants took part in the TR focus group. The VR focus group consisted of four physicians.ResultsThe main topics identified were the importance of communication for diagnostic and therapeutic processes, previous solutions to language barriers, as well as advantages and disadvantages of the two remote interpreting solutions. Advantages included the possibility to adequately communicate with language discordant patients and the high quality of the interpreting. Disadvantages included the habituation time required for new technology as well as time constraints.ConclusionOur evaluation found that these solutions were highly appreciated, if not considered indispensable, for the delivery of appropriate medical care to language-discordant patients. Differences between the two modalities were named and concrete suggestions for improvement were made. Policy-makers should consider providing VR or TR as an adequate and safe interpreting service alternative when professional in-person interpreters are not available or too expensive.

Background Gender-affirming hormones do not completely suppress fertility in transgender and gender diverse individuals, highlighting the need for counseling on pregnancy risk and contraceptive options. However, research on current contraceptive care is limited. Studies from the US have identified several barriers to care as well as facilitators, but no studies on this topic have yet been conducted in Europe. This study examined transgender and gender diverse contraceptive care in Germany from the perspective of healthcare providers, assessing its importance and their roles in it, as well as exploring barriers and facilitators. Methods Thirty semistructured qualitative interviews with German healthcare providers were conducted between December 2023 and February 2024. The interview guide included questions on contraceptive care for transgender and gender diverse individuals. Data were analyzed using structuring qualitative content analysis (Kuckartz) with deductive and inductive category development. Results Most interviewees highlighted the need for contraceptive care, depending on various factors such as the type of gender-affirming care applied, sexual practices, and transgender and gender diverse individuals’ desire for pregnancy prevention. Half of the interviewees also offered contraceptive care (depending on their specialization). Numerous barriers to contraceptive care, such as a lack of awareness of contraceptive needs, insufficient research and training programs for medical staff, have been reported, highlighting the importance of facilitators for care such as the implementation of contraceptive counseling as a standard protocol. Conclusion To improve contraceptive care for transgender and gender diverse individuals, the establishment of clear structures and responsibilities, more research, and qualifications among the involved specialties are needed. To gain a comprehensive understanding of the care situation, future research should include the perspectives of transgender and gender diverse individuals. Trial registration We obtained the approval of the Hamburg Medical Council (“Ärztekammer Hamburg”) to conduct our study by means of a “scientific case” (2023-300381-WF, September 11th 2023). Plain english summary Transgender and gender diverse people experience persistent incongruence between their experienced gender identity and their sex assigned at birth - diagnosed as gender incongruence. Many use gender-affirming hormones, such as testosterone or estrogen, to match gender identity and body. These hormones decrease the ability to get pregnant but do not stop it completely. That’s why it is important to give this population information about pregnancy risks and contraceptive options. So far, most research on this topic has come from the US, but little is known about the situation in Europe. This study looked at how healthcare providers in Germany think about contraceptive care for transgender and gender diverse people and how they experience care provision. Thirty healthcare providers (medical doctors and psychologists) in Germany were interviewed between December 2023 and February 2024. Most healthcare providers said they believed contraceptive care was important for transgender and gender diverse people, depending on factors like the type of hormones used and sexual practices, and half of the healthcare providers also offered contraceptive care. Some common challenges included a lack of knowledge about contraception for transgender and gender diverse people, lack of research, and limited training of medical staff. Healthcare providers said that better contraceptive care for transgender and gender-diverse people in Germany needs more research, clear protocols or guidelines, as well as more training for healthcare providers. Future studies should also ask transgender and gender diverse people themselves about their needs and experiences.

Background Patients with multiple long-term conditions often face a variety of challenges arising from the requirements of their health care. Knowledge of perceived treatment burden is crucial for optimizing treatment. In this study, we aimed to create a German version of the Multimorbidity Treatment Burden Questionnaire (MTBQ) and to evaluate its validity. Methods The steps to translate the MTBQ included forward/back translation, cognitive interviews ( n  = 6) and a pilot test ( n  = 7). Psychometric properties of the scale were assessed in a cross-sectional survey with primary care patients aged 65 and older with at least 3 long-term conditions ( n  = 344). We examined the distribution of responses, dimensionality, internal reliability and construct validity. Results Cognitive interviewing and piloting led to minor modifications and showed overall good face validity and acceptability. As expected, we observed a positively skewed response distribution for all items. Reliability was acceptable with McDonald’s omega = 0.71. Factor analysis suggested one common factor while model fit indices were inconclusive. Predefined hypotheses regarding the construct validity were supported by negative associations between treatment burden and health-related quality of life, self-rated health, social support, patient activation and medication adherence, and positive associations between treatment burden and number of comorbidities. Treatment burden was found to be higher in female participants ( Mdn 1  = 6.82, Mdn 2  = 4.55; U  = 11,729, p  = 0.001) and participants with mental health diagnoses ( Mdn 1  = 9.10, Mdn 2  = 4.55; U  = 3172, p  = 0.024). Conclusions The German MTBQ exhibited good psychometric properties and can be used to assess the perceived treatment burden of patients with multimorbidity.

Low-threshold e-health approaches in prevention to reduce suicide stigma are scarce. We developed an online program containing video reports on lived experience of suicide and evidence-based information on suicidality. We evaluated the program by a mixed methods design. We examined pre-post-changes of program completers (n = 268) in suicide literacy, suicide stigma (self and perceived), and self-efficacy expectation of being able to seek support in psychologically difficult situations using linear mixed models. To examine reported changes and helpful program elements 12–26 weeks after program completion, we content analyzed transcripts of telephone interviews (n = 16). Program completers showed more suicide literacy (Cohen’s d = .74; p < .001), higher self-efficacy expectations to seek support (d = .09; p < .01), lower self-stigma (subscales glorification/normalization: d = -.13, p = .04; isolation/depression: d = -.14; p = .04; stigma: d = -.10; p = .07; n = 168) compared to baseline. We found no significant differences in perceived suicide stigma. We identified lived experience reports, the possibility of sharing own narrative on stigma and suicidality, and information on support as helpful elements. The current online program can increase suicide literacy and self-efficacy expectations to seek support and reduce self-stigma. We recommend a larger randomized controlled trial with longer follow-up to confirm these findings.

ObjectivePatients with progressive chronic non-malignant diseases (CNMD) such as chronic obstructive pulmonary disease, congestive heart failure and dementia could benefit from specialist palliative home care (SPHC). The two-arm, cluster randomised controlled KOPAL trial was conducted to test the effectiveness of a timely SPHC nurse-patient consultation followed by an interprofessional telephone case conference between general practitioners and SPHC teams. This study was a component of the KOPAL trial and aims to explore general practitioners’ (GP) experiences with treating CNMD patients before and with case conferences and with the following consequences for treatment and interprofessional collaboration with SPHC teams.DesignQualitative evaluation of the KOPAL trial focussing on GPs’ perspective. Open guided interviews using narrative techniques analysed with grounded theory.SettingThe KOPAL trial was conducted in Lower Saxony and the metropolitan region of Hamburg, Germany.Participants24 GPs who participated in the intervention group of the trial were interviewed.ResultsFindings show that GPs have practice-specific routines when caring for people with CNMD. Interprofessional case conferences may lead to more awareness regarding gaps in primary palliative care, one’s own care routines or a lack of psychosocial support. Although gaining new insights, GPs follow three different strategies following the case conferences: (1) Maintain routines of care and disregard added value, (2) extend routines of care according to SPHC advice and (3) integration and partial change of care routines caused by SPHC support. These strategies are influenced by GPs’ perception of SPHC teams (eg, ambivalence towards SPHC).ConclusionInterprofessional case conferences to timely discuss care options could improve healthcare for patients with advanced CNMD by revealing gaps in care. Promoting a regular process of exchange between GPs and SPHC teams (such as through round tables) may improve a trusting cooperation.Trial registration numberDRKSS00017795.

Background Dementia is an irreversible chronic disease with wide-ranging effects on patients’, caregivers’ and families’ lives. Hospitalizations are significant events for people with dementia. They tend to have poorer outcomes compared to those without dementia. Most of the previous studies focused on diagnoses leading to hospitalizations using claims data. Further factors (e.g. context factors) for hospitalizations are not reproduced in this data. Therefore, we investigated the factors leading to hospitalization with an explorative, qualitative study design. Methods We interviewed informal caregivers ( N  = 12), general practitioners (GPs, N  = 12) and formal caregivers ( N  = 5) of 12 persons with dementia using a semi-structured interview guideline. The persons with dementia were sampled using criteria regarding their living situation (home care vs. nursing home care) and gender. The transcripts were analyzed using the method of structuring content analysis. Results Almost none of the hospitalizations, discussed with the (in-)formal caregivers and GPs, seemed to have been preventable or seemed unjustifiable from the interviewees’ points of view. We identified several dementia-specific factors promoting hospitalizations (e.g. the neglect of constricted mobility, the declining ability to communicate about symptoms/accidents and the shift of responsibility from person with dementia to informal or formal caregivers) and context-specific factors promoting hospitalizations (e.g. qualification of nursing home personal, the non-availability of the GP and hospitalizations for examinations/treatments also available in ambulatory settings). Hospitalizations were always the result of the interrelation of two factors: illnesses/accidents and context factors. The impact of both seems to be stronger in presence of dementia. Conclusions Points for action in terms of reducing hospitalization rates were: better qualified nurses, a 24-h-GP-emergency service and better compensation for ambulatory monitoring/treatments and house calls. Many hospitalizations of people with dementia cannot be prevented. Therefore, hospital staffs need to be better prepared to handle patients with dementia in order to reduce the negative effects of hospitalizations.

The management of the long-term sequelae of coronavirus disease 2019 (COVID-19) infection, known as post-COVID-19 syndrome (PCS), continues to challenge the medical community, largely owing to a significant gap in the understanding of its aetiology, diagnosis and effective treatment. To examine general practitioners' (GPs) experiences of caring for patients with PCS and to identify unmet care needs and opportunities for improvement. This study follows a qualitative design, using in-depth semi-structured telephone interviews with GPs (  = 31) from across Germany. Interviews were audio-recorded, transcribed verbatim and analysed using qualitative content analysis. GPs reported that they were often the first point of contact for patients with persistent symptoms following SARS-CoV-2 infection, with symptoms typically resolving within weeks. While ongoing symptomatic COVID-19 is perceived to be more common, the relevance of PCS to GP practices is considerable given its severe impact on patients' functioning, social participation and the substantial time required for patient care. GPs coordinate diagnosis and treatment but face challenges because of the unclear definition of PCS and difficulties in attributing symptoms, resulting in a cautious approach to ICD-10 coding. Interviewees highlight lengthy diagnostic pathways and barriers to accessing specialist care. The findings confirm the high functional limitations and psychosocial burden of PCS on patients, and the central role of GPs in their care. The study suggests a need for further research and health policy measures to support GPs in navigating diagnostic uncertainty, interprofessional communication and the limited evidence on effective treatments.