A critical analysis of the cross-sectional area Q3 in the study of human medicine and recommendations
its optimization

Economic aspects of health care have become significantly more important in the last 20 years and justify the introduction of health economics into the training of medical students. That is why the cross-sectional area Q3 “Health Economics / Health System / Public Health” was anchored in the medical licensing regulations in 2002. The design of the topics and the form of teaching was left to the institutes offering them, so that the theoretical content and the time scope of these lessons are not uniformly defined. The subject is not tied to any specific institute and is therefore shaped in Germany from the perspectives of different academic sub-fields. This results in major differences in the teaching offerings. The “Health System” and “Public Health Care” sub-areas of Q3 result from existing care structures, while the “Health Economics” sub-area has so far only existed as a discipline in economics. In addition to the 21 compulsory subjects, the medical course includes 14 cross-sectional subjects (e.g. Q1: epidemiology/medical biometry/medical informatics, Q7: medicine of aging and the elderly, Q14: palliative medicine) as well as block internships and elective subjects.

>> The aim of the changes to the licensing regulations was to make medical training for students more practical-oriented than before [1]. A new subject at the interface between medicine and economics is undoubtedly necessary in the training of doctors. However, the content of the subject of health economics can only be done in cooperation between economics and medicine, because the principles of economics should be used to increase the efficiency of medical care.
To this end, the goals of medical training must be specifically stated, the proposed paths must be feasible and the students should be able to recognize this orientation towards the training goals of the medical course. Otherwise the students will not be reached by the courses offered.
The primary goal of medical education cannot be to develop “medical business economists” who are able to reduce costs and generate profits. Undoubtedly, these goals must be achieved in order to survive economically. Medical students must be made aware that achieving these goals is part of the business administration's area of expertise.
The doctor must first define the health problem, secondly offer the different possible solutions and thirdly, the burdens that the patient and the system have to accept [i.e. especially the non-monetary costs] compared to the realistically achievable health added value - or the benefit of the care [ ie against the consequences of the care].

objective of the work
This project describes the scope and content of the health economics course in the cross-sectional area Q3 and its perception by medical students and lecturers in order to be able to derive and justify suggestions for the optimization of a sub-area.
methods
As part of a dissertation work, two questionnaires were developed with the participation of two faculties (medicine and economics), one each for the lecturers (11 questions) and one for the medical students (19 questions). Validation of the questionnaires was not planned because the validation of a questionnaire can reveal its incorrect intended use. This problem is only of minor importance when collecting simple structural data and global assessments. The questionnaires were sent to 37 universities in Germany and to 200 Ulm medical students in their 10th semester.
Results
Survey of universities
To carry out the survey among lecturers, 37 universities in Germany that offer this cross-sectional area were contacted. 26 medical faculties took part in the survey. In these 26 faculties, 21 different institutions with their teaching staff were responsible for Q3, e.g. the Department of Dermatology, Pharmacy or Preventive Medicine. Health economics was explicitly mentioned as a topic area in four institutions.
The subject is predominantly offered as a lecture, with the average length (at 11 universities) being 1.8 semester hours per week (SWS) over 16 weeks per semester, the minimum being 0.13 SWS and the maximum being 6.8 SWS. At three universities, the Q3 is offered as a combination of lecture and seminar, at two universities as a block internship, and one university combines the lecture with 1 SWS for group work. Q3 was offered at a university as a block internship in the field of social medicine. One of the 26 universities surveyed offers Q3 as a continuous course from the second to the ninth semester. 11 universities offer the subject in the third year of study (5th or 6th semester). In the fourth (or fifth) year of study, the subject is offered by seven (or three) universities. At 25 universities, an exam is held (13 of which are in multiple choice mode). Three universities require group work, a presentation or the solution of a practical task as proof of achievement in addition to the exam. The question about teaching content and main topics resulted in 59 different responses. The ten most frequent mentions are summarized in Table 1. In addition to classic health economics content, demographics, history of the health system, efficiency, effectiveness and legal aspects of medical work are offered. 14 of the 26 universities surveyed created the learning goal plan without following a public model.
Seven universities follow the model of Brennecke et al [2]. Two universities are based on the Freiburg model of Stößel and Troschke [3]. An orientation based on a catalog from the German Society for Health Economics eV (dggö) was also mentioned without reference, but this does not exist at dggö. Eight different books are recommended as literature, most frequently the works by Troschke and Stößel [4], Lauterbach, Stock, Brunner [5] and Roeder and Hensen [6]. 16 universities prefer individual design of the learning objectives, while 10 universities support their standardization (Fig.1). Fig. 2 shows that, according to the teachers, the importance of the subject Q3 is comparable to that of social medicine or ethics (n = 11), epidemiology/biometrics (n = 9), social subjects and theoretical areas (n = 5). , small subjects such as ENT (n = 1).
When asked about the content of Q3 that is not included in any other subject in the medical course, eleven respondents referred to the already answered question about the content of the cross-sectional area, in order to express that there was little overlap with neighboring subjects. The three most frequently mentioned topics, which are offered exclusively in Q3, include “Basic Questions in Health Economics”, “Basic Economic Concepts” and the “Health System, Public Health Care Lecture”.

Survey of students
The 74 responding Ulm students (24%) were in their 10th semester. The gender distribution of the answers corresponded to the distribution of students (approximately 65% female). 74% of the students found the scope of the lecture offered (1 semester hour per week) to be appropriate. 57 % considered the 10th semester to be the appropriate time for this lecture, while 18% preferred the offer in the 5th semester. The majority (54%) were of the opinion that the subject should be offered as a lecture, 27% preferred a seminar, and 15% wanted a combination of both forms of teaching. 41% emphasized the relevance of the subject of health economics for their training, while 46% emphasized this
doubted relevance.
When comparing the importance, 73% of the students saw health economics in the neighborhood of epidemiology/biometrics, 23% in the neighborhood of social medicine and ethics. Whether disadvantages for patients would be expected if the subject of health economics were not offered was answered in the negative by 84% of the students. Among those who expected disadvantages, 42% feared a lower quality of life, 25% feared a longer stay in hospital without worsening the prognosis, 17% feared functional limitations after treatment and 8% feared life-threatening disadvantages. Only 16% of the students suspected that teaching health economics would optimize economic activity; 58% consider this effect to be possible, while 24% do not expect this advantage. Whether clinical situations that have already been experienced are assessed differently due to health economic considerations than without them was answered in the negative by 47%, 45% said that they had experienced such situations occasionally, 7% often and 1% very often. Health economics would offer a new perspective to assess clinical problems were confirmed by 47% but denied by 53% of students. 73% of the students see the subject of health economics as having no advantage for working in everyday clinical practice, including patient care, and 55% fear that health economics will not convey any relevant aspects for their future career. In agreement with this, 73% of the students stated that they were unable to derive any concrete action and treatment strategies for future everyday work from the teaching content.
65% deny that the subject of health economics offers knowledge that has not already been taught in any other subject; on the other hand, the other students complain that too many considerations about economic aspects and balance sheets are discussed that have no connection to clinical medicine. 40% of the students who took part in the survey stated that they had not attended any of the lectures; 8% of the students attended all lectures. 5% rated the content of the subject area of health economics as very relevant for medical training, 46% as relevant, 35% as less relevant and 7% as not relevant. The need for basic principles (e.g. evidence-based medicine) for clinically meaningful decisions is rated as very important or important by 56%, less important by 32% and unimportant by 5%. The scientific foundations of health economics are rated as very important or important by 39% of students, while 54% rate them as less important or unimportant. 73% of students consider the information on health insurance systems to be very relevant or relevant. The majority of students (58%) also found the topic of hospital management to be very relevant or relevant.
Conclusions
discussion
Since we are not aware of any comparable analysis of the new cross-sectional area Q3, only our own observations and ideas about the design of Q3 can be discussed. The description by Behman et al. for Q3 does not contain any assessment of content and was not designed to revise the teaching content [7]. Our analysis is limited to the area of health economics in the cross-sectional area Q3, because the other two areas of Q3, health system and public health, are defined by the care structures.
The results confirm a high degree of variation in the scope and content of the subject of health economics. The very different assignment of Q3 to existing chairs or institutions also explains why the new subject is based on different concepts at the universities.
The low participation of students in the survey (24%) also corresponds to the low acceptance of the lectures offered at our university and reflects the importance that is attached to this subject from the students' perspective. This judgment cannot be transferred to other universities due to the significant differences in content of the subject. Only the statements of the lecturers who described the courses offered at their universities as part of this project are comparable.
Due to the increasing importance of economic aspects in healthcare, many colleagues saw the need to deal with business aspects of healthcare. A business economist will only be able to assess the risks of screening results, the accuracy of diagnostic tests and the probability of a cure or palliative therapy success in layman's terms. We expect the doctor to have knowledge of the basic medical principles. In addition, the doctor must be able to weigh the costs and consequences of medical decisions. It must be clear that it is not about monetary units, but about values.
Figure 5 shows that the professional contributions of business economists and doctors differ significantly.
Design options
The core message that needs to be conveyed to prospective doctors concerns the necessary weighing up of “effort” and “return” or “costs” and “consequences” of different options for action. Figure 5 shows that there are two trade-offs. The first of these two (economic) considerations corresponds to a medical task. The doctor - and no other actor in the system - must ensure that the medical effort, i.e. the burdens and risks that the patient is expected to face, is balanced against the return, i.e. the realistically achievable care goal or the added health value achieved. This decision initially has nothing to do with money. It is a balancing of values.
Scientific evidence is undoubtedly the basis of every decision. Ultimately, however, additional aspects, such as values, flow into the decision-making process [8]. Any experienced doctor can carry out this weighing of values (!) intuitively and accurately without having to calculate the QALYS (quality-related life years) or other indicators gained.
The second of these considerations corresponds to a business management task. This task should be assigned to a business economist. She/he must ensure that the monetary expenditure, ie the burdens and risks that are expected of the company, compared to the earnings, ie together with the achievable income, result in a balanced balance. This decision concerns the monetary costs. Figure 1 shows that the medical and business considerations must be balanced and together will determine the economic survival of the company.
A second problem concerns the suitability of the available outcome data for everyday use. In the foreseeable future, service providers will not be able to avoid documenting two goals in the context of health care research: The care goals expected under everyday conditions must be derived from results that were collected under ideal conditions of an experimental study, a Randomized Controlled Trial (RCT) (efficacy). In contrast, the results (effectiveness) that can actually be achieved under everyday conditions must be described in a non-experimental but controlled observational study, a Pragmatic Controlled Trial (PCT), which is carried out under everyday conditions. The differences between the two conditions and methods, RCT and PCT, have been compared [9] and recently emphasized in a current statement [10]. The demand for this distinction was recently articulated in the German Medical Journal [11]. Under the title “Organization, planning and control in medicine. Against heteronomy and deprofessionalization” were the attitudes that
Skills and knowledge are required that can be conveyed in the cross-sectional area Q3.

Justification for the possible design
Although no one doubts the difference between results under ideal conditions (efficacy) and the care results under everyday conditions (effectiveness), hardly anyone has paid attention to it, even though Archie Cochrane pointed out the importance of this difference 40 years ago:
“Between measurements based on RCT and benefit. . . in the community there is a gulf which has been much underestimated”
[12].
To this day, it is the international standard to base guidelines and medical recommendations on studies.
animals that were carried out under ideal conditions. It is the task of the colleagues who define the content of medical training to question the current orientation towards the gold standard of RCT.
The skepticism of experienced practitioners regarding the results of some important clinical studies should make us sit up and take notice. If technical errors are subsequently demonstrated in these studies [13], the users of these results should be informed about these new findings. Reports of technical errors in clinical studies have increased significantly in the literature in recent years. Since 2000, when documentation of the objectives of large trials (direct costs > $ 500,000/year) was required [ClinicalTrials.gov], the proportion of trials with positive results has reduced from 57% to 8% [14]. An analysis of 20 pediatric studies showed that in 19 of these studies, the planned questions of the study did not correspond to the published answers [15]. These important differences remain hidden from the reader who uses scientific reports as a source of information without examining the validity of these reports. It is only rarely that statements that are difficult to understand can be identified in a publication. An example of this is the “non-inferiority of a new therapy to placebo” [16].
Through the development and application of instruments for assessing the validity of RCTs [17] and systematic reviews [18, 19], errors have been uncovered that call into question the justification of recommendations for action using these documents. The considerable variations that were observed by comparing international guidelines using the examples of esophageal carcinoma, gastric carcinoma, pancreatic carcinoma and colon carcinoma in four dissertation theses also indicate the need to confirm the suitability of these recommendations for everyday use they are published as care recommendations.
The reported problems are not exceptions [20]. The causes of these problems are based on various conflicts of interest and are therefore difficult to control. An example is the hardly affordable fees charged by some scientific journals for error corrections in published papers [21]. The use of research funds for this requirement will discourage some authors from publishing correction reports.
Our working group took up the task of overcoming the “efficacy-effectiveness gap” 10 years ago [22]. As a result of this cooperation with various working groups, the Pragmatic Controlled Trial (PCT) method was recently published [23], which allows a comparative description of effects under everyday conditions without randomization. The PCT differs from the RCT based on eight criteria.
The evidence-based distinction between RCT (efficacy studies) and PCT (effectiveness studies) shows that the exclusive focus of clinical research on randomized controlled trials (RCT) leads on the wrong track:
• RCTs cannot be replaced if the “efficacy”, the effect of an intervention under interference-free ideal conditions, can be proven,
• RCTs cannot make any statements about the effects of these interventions under everyday conditions,
• RCTs cannot demonstrate either over- or under-provision under ideal conditions [10].

Recommendations for economical, appropriate, useful and
Appropriate care can only be justified by data that describe the effects that can actually be achieved under everyday conditions. This work is intended to motivate medical students and medical colleagues to discuss clinical economics as a new training subject in order to confirm that doctors should base their decisions primarily on values and only secondarily on costs [24]. <<