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

2007; 29: e269–e275

WEB PAPER

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

REGINE WOOD TILLMANNS1,2,4, ANNA RINGWELSKI1, JOHANNA KRETSCHMANN2,LUITA D. SPANGLER3 & RAYMOND H. CURRY1

1Northwestern University Feinberg School of Medicine, USA, 2Charite – Universitatsmedizin Berlin, Germany, 3FreieUniversitat Berlin, Germany, 4Texas Tech University Health Sciences Center School of Medicine at El Paso, USA

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 Charite–

Universitatsmedizin 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 (1¼ best/agree

the most and 5¼worst/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 Charite - Universitatsmedizin 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 extend-

ing into the third and fourth years as well, the course is

designed to provide a comprehensive, integrated introduc-

tion 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).

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

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.

Correspondence: Regine Wood Tillmanns, MD, FACP, Texas Tech Health Sciences Center, Department of Internal Medicine, School of Medicine at

El Paso, 4800 Alberta Avenue, El Paso, Texas 79905, USA. Email: [email protected]

ISSN 0142–159X print/ISSN 1466–187X online/07/09-100269–7 � 2007 Informa UK Ltd. e269DOI: 10.1080/01421590701551706

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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 (Schuppel et al. 1998; Kiessling et al. 2003;

Schildmann et al. 2004; Burger 2006).

The Charite – Universitatsmedizin 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

& Loholter 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 Charite –

Universitatsmedizin 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 Charite –

Universitatsmedizin 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 Charite – Universitatsmedizin 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 ofAugust 2006

By August 2006, a total of 142 students had participated in the

course during four different sessions. Almost 75% of partici-

pants to date have been female, compared to a female

student body of approximately 64% at the Charite –

Universitatsmedizin Berlin (Humboldt – Universitat 2005).

Questionnaires. Upon the conclusion of the course, students

completed a questionnaire addressing course content, effi-

ciency, 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.

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.

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.

R. W. Tillmanns et al.

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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).

Discussion

Contributions to social aspects of medical educationin 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 Charite 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

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 n¼70 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.

How would you rate your knowledge in the subject of:

0

2

4

6

8

10

Cultural Diversity p=0.00

Mistakes p=0.00

End-of-Life p=0.00

Vulnerable Groups p=0.00

Pharm. Industry p=0.00

Sca

le pre, n=14 2

post, n=133

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, 10¼ 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?’’ N¼ 142 pre-course survey responses. N¼ 133 post-course

survey responses.

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 n¼136 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.

The profession of medicine

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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 profes-

sionals, 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 consider-

able 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

How would you rate your interest in the subject of:

0

2

4

6

8

10


Mistakes p=0.04

End-of-Life p=0.00



Sca

lepre, n=142

post, n=133

Figure 2. Result of pre- and post-course surveys assessing students’ interest in the course topics.


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?’’ N¼ 142 pre-course survey responses. N¼ 133 post-course

survey responses.

How would you rate your professional attitude in the area of:

0

2

4

6

8

10


Mistakes p=0.01

End-of-Life p=0.00



Sca

le pre, n=142

post, n=133

Figure 3. Result of pre- and post-course surveys assessing students’ professional attitude toward the course topics.


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?’’ N¼ 142 pre-course survey responses. N¼ 133 post-course survey responses.


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School of Medicine, only five could be integrated into this

one-week version at Charite – Universitatsmedizin 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 encour-

aged changes within medical education – immigrant

initiatives (Fox 2005), gender equality (Vlasoff & Garcia

Moreno 2002), the hospice and palliative medicine move-

ment (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 Charite – Universitatsmedizin

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 Charite – Universitatsmedizin 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 introduc-

tion 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 Charite – Universitatsmedizin 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 Charite – Universitatsmedizin 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 collabora-

tion. Other logistical barriers will remain, however, not the

least of which is difficulty in providing small group settings

to the large Charite – Universitatsmedizin 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 Charite’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.


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Future prospects

Despite upcoming changes in course leadership,

‘‘The Profession of Medicine’’ will continue to exist as an

elective at Charite – Universitatsmedizin 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.

Notes on contributors

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 Charite – Universitatsmedizin Berlin, Germany. She is now

assistant professor at Texas Tech University Health Sciences Center at

El Paso, Texas, USA.

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, 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 Charite –

Universitatsmedizin Berlin, involved in program development

and evaluation.

LUITA D. SPANGLER, PhD, received her doctorate in English Literature

at the University of New Hampshire, USA. She currently teaches

English at the Freie Universitat Berlin and the Universitat Potsdam,

Germany.

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.

Acknowledgements

The authors would like to thank Ulrike Arnold, Director of

Charite International Cooperation at the Charite –

Universitatsmedizin 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 participa-

tion and continued involvement and leadership.

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Documents

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