[Integration of scientific literacy into medical school curricula, residency programmes and continuing medical education]

 Renate Deinzer ¹
 Henning Schliephake ²
Erika Baum ³
Christian Baxmann ⁴
Julia Eckel ⁵
Henrik Herrmann ⁶
Il-Kang Na ⁷
Nathalie Huber ⁷
Andreas Stallmach ⁸
Tobias Weberschock ⁹
Diana Wolff ¹⁰
Rolf-Detlef Treede <sup>11,12

1</sup> Institute of Medical Psychology, Department of Medicine, Justus Liebig University Giessen, Germany
² Department of Oral and Maxillofacial Surgery, University Medical Center Göttingen, Georg-August University, Göttingen, Germany
³ Institute of General Medicine, University of Marburg, Germany
⁴ Federal Association of Medical Students in Germany (bvmd), Berlin, Germany
⁵ Division of Academic Affairs and Development, Mannheim Medical Faculty, Heidelberg University, Heidelberg, Germany
⁶ Training Center for Healthcare Professions, Westküstenklinikum, Heide, Germany
⁷ Berlin Institute of Health (BIH) at Charité Clinician Scientist Program, Berlin, Germany
⁸ Jena University Hospital, Department of Internal Medicine IV (Gastroenterology, Hepatology, and Infectious Diseases), Germany
⁹ Goethe University Frankfurt, Institute of General Medicine, Frankfurt EBM Working Group, Frankfurt am Main, Germany
¹⁰ Department of Conservative Dentistry, Heidelberg University Hospital, Heidelberg Medical Faculty of Heidelberg University, Heidelberg, Germany
¹¹ Department of Neurophysiology, Mannheim Center for Translational Neuroscience (MCTN), Mannheim Medical Faculty, Heidelberg University, Heidelberg, Germany
¹² Department of Psychiatry and Psychotherapy, Central Institute for Mental Health, Mannheim Medical Faculty, Heidelberg University, Heidelberg, Germany

Abstract

Objectives: Curricula of medical and dental schools at German universities as well as subsequent residency programmes aim to provide science-based education and to prepare their graduates for continuing medical education throughout their professional lifetime. In contrast to many other university degrees, scientific literacy plays a minor if any role in current curricula. The Berlin Forum hosted by the Association of Scientific Medical Societies in Germany (AWMF) on 17 November 2023 aimed to evaluate, how this deficit may be amended and to what extent this process can be based on existing pilot projects.

Methods: Invited experts from scientific medical societies, medical and dental faculties, the German medical association and other institutions involved in graduate and postgraduate medical and dental training discussed requirements for and examples of best practice of scientific literacy training in medicine and dentistry. Writing teams extracted the key messages for this article.

Results: The Association of Scientific Medical Societies in Germany (AWMF) recommends:

– To include a longitudinal scientific literacy track as a mandatory requirement in medical and dental school curricula.
– To include development of methodological and practical competency in evidence-based patient care and medical research as a mandatory requirement into residency programmes.
– To credit at least six months of work in clinical or health services research towards fulfilment of residency programmes.
– To integrate scientific literacy as a regular part of continuing medical and dental education programmes.

Conclusions: Scientific literacy is a key competency for responsible medical care. It is also a prerequisite for progress in medicine. Development and maintenance of scientific literacy therefore deserve greater attention than today in medical and dental school curricula, residency programmes and continuing medical and dental education. Results of the Berlin Forum 2023 hosted by AWMF demonstrate that this reform is possible and how it may be achieved.

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1 Introduction

As a result of a symposium organised by the Association of Scientific Medical Societies in Germany (AWMF) with junior organisations of scientific medical societies (10 March 2008 in Mainz), the AWMF has since been calling regularly for the inclusion of a training objective “Teaching scientific methods in medicine” in the list of §1 of the Licensing Regulation for Medical Doctors (Approbationsordnung für Ärzte, ÄApprO; Table 1 [Tab. 1], see also [1]). As part of the development of the National Competency-based Catalogue of Learning Objectives (NKLM-1; [2]) , proof of scientific competence was included as one of five milestones in future medical training. The drafts of a revised ÄApprO by the Federal Ministry of Health (Bundesministeriums für Gesundheit; BMG) have included this training objective since 2020 in its §1 “Objectives of medical training” [3], [4]. However, in current medical training and practice, scientific thinking and action still plays a subordinate role compared to the acquisition of medical knowledge. This core medical competence is also neglected in residency and continuing medical education (CME) programmes. Even courses in the methods of evidence-based medicine (EBM) are frequently not awarded CME credits by the regional Medical Associations (Landesärztekammern).

A 2017 position paper by a Senate Commission of the German Research Foundation (DFG) emphasised that a good basic education in scientific thinking and action is essential for the further development of clinical research in Germany [5]. In a 2022 position paper, the National Academy of Sciences (Leopoldina) pointed out that healthcare provision for citizens in Germany can only fulfil its legal mandate if those involved are able to rationally assess and implement scientific findings [6].

These position papers emphasise that the acquisition and maintenance of scientific competence is not given the attention it deserves in medical education, residency training and continuing professional development. As a result, young doctors continue to be inadequately prepared for clinical practice, where they will be permanently challenged to integrate new scientific findings into their own medical practice. This problem becomes even more critical in the current times of information overload due to the internet and artificial intelligence, when it becomes even more important to be able to assess the scientific basis of the information provided using one’s own scholarly skills.

In the current position paper, the AWMF evaluates opportunities for teaching scientific competence in medical schools and residency programmes within the current legal framework, and how this framework should be expanded through legal changes by health policymakers and Medical associations (Ärztekammern). In addition to human medicine, teaching of dentistry is also addressed.

2 Methodology

At the AWMF Berlin Forum on 17 November 2023, experts from the AWMF member societies, medical faculties, medical associations and other institutions involved in basic and postgraduate medical education gave presentations on the status quo and future prospects for teaching scientific competence to current and future generations of medical doctors (Table 2 [Tab. 2]). The strengths and weaknesses of the current and planned teaching of this core medical competence were discussed with students and trainees as well as with scientific organisations. The content of the presentations and discussions and the recommendations derived from them were compiled into a draft text. This was agreed upon several times by the participating speakers, discussed in detail by the AWMF Board and agreed upon by all participants in the present final version.

3 Scientific competence as a key qualification for all medical activities

3.1 What is scientific competence in medicine?

The Duden dictionary defines medicine as the science of the healthy and ill human organism, its diseases, their prevention and cure [7]. Medicine is therefore a science in itself. Logically, fully trained doctors should be scientifically competent. But what is meant by scientific competence here?

In epistemological terms, knowledge can be understood as information that helps us to better navigate the world or to solve problems more effectively. Medical knowledge should achieve exactly the same. It should be well-founded and substantiated. Well-founded knowledge may then be called insight [8].

In Germany, Article 5 (3) of the Constitution guarantees that science, research and teaching are free. This is the basis for ensuring that insights can be gained without the influence of distorting interests and can be imparted in academic teaching. In medicine, these insights are primarily aimed at optimising medical patient care. This distinguishes medicine from many other sciences due to its strong emphasis on practical skills. For this reason, medicine is generally understood as a practical science [9].

This means that medical science is not only concerned with generating new knowledge about health and disease, but also with communicating this knowledge to students and implementing it in specific treatment situations. The latter always serves to gain knowledge, whether in relation to individual patients or as a stimulation for further research in this area of application. This concept is reflected in the sub-functions of the physician’s role as a scholar, which were included in the NKLM (Figure 1 [Fig. 1]).

From medical science in everyday medical practice, including research, teaching and patient care, it is now only a small step to scientific competence in medicine. In a broader sense, competencies are observable, successful problem-solving skills [10]. In medicine, this results in scientific competence as the ability to generate scientific knowledge and to identify, communicate and use the best available knowledge to solve medical problems. This also includes the ability to recognise and take into account limitations in the validity of the available scientific evidence. Scientific competence is therefore a competence that transcends individual specialist areas and medical content, describing the approach and methodology as well as a critical attitude towards knowledge and findings in medicine.

3.2 Who needs scientific competence in medicine?

Scientific competence is therefore a key qualification for medical doctors and should therefore be implemented as a learning objective in the Licensing Regulations for Doctors (ÄApprO) and in continuing medical education (CME). This is particularly important in light of the fact that the flood of scientific data and digitalisation are changing the requirements profile for medical practice. In addition to clinical factual knowledge, the practice of evidence-based medicine is becoming significantly more important [6], [11].

In other academic subjects such as biology or psychology, knowledge and skills in scientific thinking and action are required as part of the regular university curricula through in-depth research projects (including bachelor’s/master’s theses). In contrast, medical studies do not explicitly anchor the teaching of scientific competence in the curriculum. Specific internships, scientific term papers or elective courses that are explicitly dedicated to this topic are only available at a few locations. Even the common practice of starting a medical doctoral thesis during one’s studies cannot compensate for this deficit, as scientific skills are only acquired and practiced selectively in this context, in relation to the topic of the dissertation. Conceptually, a dissertation is only intended to follow comprehensive basic scientific training and does not replace it. This becomes even clearer in specialist medical training, where the acquisition of scientific qualifications or scientific work depends primarily on the individual career goals of the trainees – knowing full well that the acquisition of scientific skills must usually be done in addition to regular specialist medical training [12]. Certificates of achievement in the context of medical studies and specialist training for advanced scientific qualifications are not yet mandatory, and thus there is currently a lack of systematic teaching of scientific skills throughout the training and advanced education of young doctors.

In order to practise their profession in an evidence-based manner, all clinically employed doctors must continue to develop their scientific competence throughout their lives; this knowledge and practical competence is therefore not only relevant for researchers but for all Medical Doctors. Lifelong cultivation of one’s own scientific competence is essential because diagnostic and therapeutic concepts for people with medical conditions have changed dramatically in recent decades. Nowadays, the goal of treatment is no longer short-term relief from symptoms. In addition to quality of life with long-lasting remission and full restitution the focus is on limiting side effects. This has been achieved, among other things, through revolutionary developments in pharmacotherapy – for instance, the introduction of biologics.

The process and outcome quality of modern therapies is promoted by clinical practice guidelines, as has been scientifically proven many times. The quality of the guidelines is in turn ensured by a set of regulations issued by the AWMF [13] (https://www.awmf.org/leitlinien/awmf-regelwerk.html). In addition to providing specific decision-making aids, guidelines also define the diagnostic and therapeutic areas in which there are deficits in care in the sense of over-treatment, under-treatment or mistreatment. The effectiveness and thus ultimately the benefit for the individual patient depends not only on the quality of the guidelines but also on their implementation by clinical practitioners.

Numerous barriers stand in the way of implementing the guidelines: In addition to a lack of time in clinical work, a partly poor applicability in practice and a lack of knowledge, a recent review [14] points to insufficient training of physicians in the use of guidelines. Given that, for example, almost every second surgical trainee feels they have personal deficits in medical decision-making and knowledge of rational decision-making, this seems paradoxical [15]. To overcome these deficits, the principles of guideline-based work in medicine were included as examination content in the competence-based subject catalogue for medicine [16]. It is now important that the faculties take up this task and consistently implement the necessary training for working with guidelines.

Scientific competence is therefore required, firstly, to train young scientists in the academic field of medicine and, secondly, to enable practicing doctors to carry out their professional activities in accordance with modern, evidence-based medicine.

3.3 The importance of acquiring scientific competence from the student’s perspective

For scientific training in medical studies to be successful, it must also be carried out in the interests of the student body. But how satisfied are students currently with the teaching of scientific skills?

Data from 2015 show that only 22.7% of the students surveyed feel that their studies have prepared them well for a dissertation. This is also reflected in their self-assessment of certain scientific skills. 69.5% rated their skills in statistics as very poor or rather poor, and 55.4% rated their skills in scientific writing as very poor or rather poor [17].

Nevertheless, a large proportion of students consider scientific skills to be essential in medical practice. 93.2% of students agreed with the statement that critical analysis of texts is a core medical competence. Many students (73.0%) would like to see more courses on this topic in particular, so that they can acquire scientific skills during their studies. The situation is similar for other teaching formats on scientific writing (67.8%), good scientific practice (60.0%) and journal clubs (54.6%), which the majority would like to attend more during their studies [17].

The results of the survey show that the majority of students are not satisfied with the teaching of scientific skills and would like an improvement in the situation.

This is also reflected in the position of the student representative body, the Federal Representation of Medical Students in Germany (bvmd). In its 2016 position paper on science and doctoral studies, the bvmd called for a strengthening of the teaching of scientific skills – among other things in the form of a compulsory scientific thesis [18].

It should be noted that medical studies must primarily train students for future clinical work. The 2022 Career Monitoring Survey conducted by the National Association of Statutory Health Insurance Physicians (Kassenärztliche Bundesvereinigung; KBV) shows that only 35.1% of the students surveyed consider it important or very important to be able to participate in research topics and studies in their professional lives. After completing their specialist training, only 28.3% consider taking up a position in clinical research and 12.7% consider taking up a position in research without patient contact [19]. The teaching of scientific skills should therefore focus primarily on teaching the basic knowledge and skills that are also relevant to clinical medical practice. Given the already very high workload during their studies, intensifying the teaching of scientific skills should not place an additional burden on students.

Against this background reprioritising teaching content is necessary. First and foremost, the scope and depth of detail of the factual knowledge currently being taught should be questioned. In view of modern information technologies, cutbacks are conceivable here, which should be made in favour of a stronger focus on skills – including scientific skills.

4 Teaching scientific competence in medical schools

Without an understanding of the scientific methods used to generate knowledge in medicine, it is impossible to fully comprehend the findings themselves and assess their significance. It is therefore important that students are introduced to scientific thinking and action in medicine from the very beginning of their studies. They should learn which scientific methods are used to gain knowledge in medicine, they should be able to critically assess the quality of the methods and the significance of the data obtained with them, and they should ultimately be able to apply these methods themselves in an appropriate manner [20]. However, the regulations governing the Licensing Regulations for Doctors (ÄApprO) do not specify that scientific competence should be taught as a separate curricular structure. The fact that it is nevertheless addressed, at least in part, is due to its inclusion in the IMPP-GK subject catalogues. These devote separate chapters to the topic in the sub-catalogue “Fundamentals of Medical Psychology and Medical Sociology” for the first section of the medical examination and in chapter D1 of the new GK for the second section of the medical examination. Chapter D1 is already based on the National Competence-Based Subject Catalogue for Medicine (Nationaler Kompetenzbasierter Gegenstandskatalog Medizin; NKLM). The following section outlines how the topic is covered in this catalogue.

4.1 Scientific competence in the National Competence-Based Learning Objectives Catalogue for Medicine

Version 2.0 of the National Competence-Based Learning Subject Catalogue for Medicine (NKLM) was adopted in 2021 and published online at https://www.nklm.de [21]. The aim of the NKLM is to describe the competencies that all medical students should acquire as part of a core curriculum.

The teaching of scientific competence is presented jointly in the NKLM in the areas of research, learning/teaching and patient care and developed longitudinally throughout the entire course of medical studies. The competencies to be achieved at the end of this longitudinal training are summarised in the NKLM graduate profile, while the learning objectives in Chapter VIII.1 – Medical-Scientific Skills describe the content and the path to achieving them.

Based on the CanMEDS roles originating in Canada, the graduate profile describes eight different medical competency roles that future doctors should fulfil in their everyday professional lives [22]. The acquisition of scientific competence is anchored in the NKLM in the role of the scholar (Figure 1 [Fig. 1]). The skills described there are divided into the ability to engage in lifelong learning, to critically apply scientific sources in the sense of evidence-based medicine (EBM), and to take on the role of teacher and researcher (“innovator”).

The role descriptions are followed in the graduate profile (Figure 2 [Fig. 2]) by the entrusted professional activities (Anvertraubare Professionelle Aktivitäten; APT) and the professional scientific activities (Professionelle Wissenschaftliche Tätigkeiten; PWT). APT and PWT serve to summarise and describe competencies in terms of observable and particularly relevant activities in everyday professional life. While the content of the critical application of scientific knowledge in the sense of EBM is anchored in the clinically assigned APT, the two PWT describe the ability to present scientific questions in a research team and the ability to carry out a research project under supervision in the sense of doctoral work.

To ensure that students are able to assume the role of scholar described in the graduate profile, as well as the APT and PWT, by the end of their studies, the necessary medical and scientific skills are described in Chapter VIII.1. Chapter VIII covers all the higher-level competencies in the NKLM that all students should have mastered to a comparable level at the start of their careers, regardless of their future specialisation. The medical-scientific skills in VIII.1 are operationalised in 7 competence areas via specific learning objectives (Figure 1 [Fig. 1]). These learning objectives serve to highlight a longitudinal strand which, as a learning spiral, repeatedly revisits the most important scientific skills and deepens and extends them in different professional contexts. Based on basic learning objectives and learning objectives in the sub-role as learners, basic knowledge and fundamental skills are acquired, which are later deepened in the sub-roles as critical users, innovators and teachers and applied as professional skills in the sense of action competencies. The various scientific aspects of research, learning and teaching, and patient care should complement and support each other in order to convey a comprehensive understanding of the scientific basis of the medical profession. Finally, the learning objectives of the chapter therefore specifically require the completion of supervised scientific work and the creation of evidence-based diagnostic and therapy plans for specific patients. Across all learning objectives, teachers have the emotional task of acting as role models, conveying the joy of science-based medicine and awakening professional curiosity.

4.2 Example of teaching scientific competence in medical studies

Strengthening scientific skills in medical studies was defined years ago as an essential goal of the new curriculum at the Mannheim Medical Faculty (MaReCuM). First, an inventory of scientific teaching in MaReCuM was carried out, which revealed an already existing implicit scientific curriculum [23]. To further develop the curriculum, a joint definition of basic scientific skills for all medical disciplines and an expert consensus on the content and scope of the scientific curriculum were established as a basis.

As a result, a compulsory credit requirement for Cross-Sectional Area (Querschnittsbereich; QB) “Scientific Work” was included in the study regulations for the MaReCuM model curriculum [24] at the Mannheim Medical Faculty on the basis of § 27(2) ÄApprO 2002 [25]. Successful completion of the QB “Scientific Work” performance assessment has been mandatory since the 2015/16 winter semester and includes courses on literature research, introduction to evidence-based medicine, good scientific practice, critical evaluation of scientific evidence, and scientific writing, and concludes with a research paper. With the research paper, students demonstrate that they are capable of working scientifically.

The QB is accompanied by other science-oriented courses from the previously implicit science curriculum, which has been supplemented by additional courses: an introductory course on scientific work, laboratory practicals in the basic subjects, courses on experimental design, biomathematics and epidemiology, and evidence-based medicine in the clinic. Scientific references are integrated into teaching as standard in MaReCuM. In addition, there is a compulsory elective area with the preclinical elective “Clinical Research” and the clinical elective “Translational Research” as well as extracurricular offerings, e.g. the Day of Science in Medical Studies.

Curriculum analyses showed that many courses were already implicitly focused on the topic of scientific rigour. It was therefore necessary to align the topics in a teaching strand coordinated across all subjects and to supplement them where necessary. A lot of space is needed in the curriculum so that critical, scientific and systematic approaches can be understood, implemented and reflected upon. In this context, students must also be shown the relevance of basic scientific training for everyday clinical practice, as this is not always intuitively recognised. In order for students to recognise the importance of scientific thinking and action for medical research and practice in the long term, it is essential to involve teaching staff who take a critical scientific approach to teaching and exemplify scientific thinking and action in everyday clinical practice.

The courses in the scientific curriculum are evaluated positively by students in module and semester surveys. The specially developed information system FAM (ForschungsArbeitsManagement) is used for the administrative processing of research work (i.e. topic announcement, registration, submission, evaluation of research work). By the end of 2023, approximately 1,250 research projects had been completed at the Mannheim Medical Faculty, involving approximately 110 clinics, institutes and facilities. Almost two-thirds of the students were motivated to deepen their scientific work in the context of a doctoral thesis.

Potential additional costs are repeatedly cited as an obstacle to implementing measures to improve graduates’ scientific competence. This example shows that it is already possible to provide a more intensive, high-quality scientific education at undergraduate level by reorganising teaching and administrative tasks at a manageable financial cost.

4.3 Teaching scientific skills in the study of dentistry

As part of dental training, the acquisition of scientific competence is embedded in the new Licensing Regulations for Dentists in 2019 (ZApprO; [26]). This stipulates that dental training must be conducted on a scientific basis and that the principles of evidence-based evaluation of medical and dental procedures (see §1 (2) ZApprO 2019; [26]) must be taught. The inclusion of the cross-sectional area “Scientific Work” implements a longitudinal scientific strand in the curriculum, which teaches interdisciplinary scientific work with a focus on medical biometrics, medical informatics, literature research and evaluation, and evidence-based medicine. Success can be assessed by means of a seminar paper (scientific paper) with a final discussion or a written examination at the end of the course. The contents of this cross-sectional area are finally examined in writing as part of the written part of the third section of the nationwide dental examination (Z3), thus ensuring a multi-stage assessment of the training content.

The role of the dentist as a scholar is also anchored in the National Competence-Based Learning Objectives Catalogue for Dentistry (NKLZ; [27]) through corresponding learning objectives. Together with the cross-sectional areas specified in the ZApprO, these ensure the acquisition of competencies within the framework of dental training and are intended to guarantee the ability to critically evaluate and apply scientific information and its sources. As in medicine, dentists also act as teachers for various target groups in the practice of their profession and contribute to the development, dissemination, application and translation of new scientific findings and dental/medical practices.

With its new licensing regulations from 2019, dentistry is thus leading the way in firmly and visibly anchoring the topic of scientific competence in medical education, while the equivalent learning objectives of the NKLM for human medicine have still not been implemented across the board.

5 Expansion of scientific competence in postgraduate education

5.1 Current status of teaching scientific competence in postgraduate education in human medicine

The current model postgraduate education regulations of the German Medical Association (Bundesärztekammer; BÄK) provide for the teaching of the scientific foundations of medical practice for all area-specific programmes – but only as knowledge and not as practical competence. Scientific rigour is thus a constitutional element of postgraduate education (residency programmes), albeit only at a low level of competence so far. However, particularly for the role of the physician as a “scholar”, scientific competence should be taught in addition to subject-specific medical skills, both for the application of scientific findings and guidelines in evidence-based medicine on the one hand, and for the ability to critically reflect on and manage scientific data on the other. Scientific competence is therefore an integral part of the medical profession and is therefore also an indispensable part of continuing medical education (CME).

Postgraduate medical training after completing a degree in human medicine has a decisive influence on the attitudes and values of the medical profession and represents a phase in the development of young doctors in which medical expertise is acquired. It requires a medical licence, i.e. unrestricted permission to practise medicine, and therefore generally takes place within the framework of residency. The initial aim of postgraduate training is to deepen, focus and specialise professional knowledge and to obtain specialist status in order to work in outpatient medicine in accordance with the provisions of the Social Security Code V. The current state of science and the application of evidence-based medicine play a major role in ensuring high-quality patient care.

The specific requirements for postgraduate medical education are defined in accordance with the laws governing the medical professions (Heilberufekammergesetze) by the State Chambers of Physicians (Landesärztekammern). These associations are responsible for the planning, implementation, evaluation and further development of postgraduate residency training. Within the framework of the federal structure of the Federal Republic of Germany as laid down in the Constitution, they draw up regulations in their chamber regions based on a model postgraduate training regulation (Muster-Weiterbildungsordnung) has been drawn up at federal level with the active participation of professional societies and associations, thereby establishing the legal framework, the training periods and content. The core principles are that postgraduate training is carried out under the responsible supervision of doctors authorised by the respective state medical association who are in direct contact with the trainees. It must take place in an approved postgraduate training facility with a defined time frame, specified content and documentation in the eLogbook, and concludes with an examination.

Since 2018, the concept of competence-based training has been anchored in the model training regulations and subsequently in all training regulations of the 17 State Chambers of Physicians, with a focus on cognitive and methodological skills as well as practical skills, emphasising medical attitudes and roles. The latter is laid down in the preamble, in the general content and specifically in the postgraduate training content in the specialist areas (Figure 3 [Fig. 3]). The acquisition of scientific competence for the medical role of the scholar is only specified to a limited extent (see Table 3 [Tab. 3]). It can be acquired, among other things, through research activities. Such research periods can also be credited towards postgraduate training, provided that they serve as patient-related research and at the same time contribute to the acquisition of practical clinical skills.

Despite the clear requirements for the teaching of scientific competence specified in the postgraduate training regulations, the critical question arises as to whether, in current practice, the attitudes and thus also the scientific competence can really be taught in everyday residency programmes. There is often a lack of human and financial resources for this, and surveys and evaluations indicate a lack of time due to increasing work intensity and economisation in the healthcare system, which is detrimental to postgraduate training. Current practice is therefore strongly oriented towards clinical-practical content and takes place predominantly within the framework of routine care (learning by doing) [28]. There is little protected time for teaching units, reflection and feedback, and the content of the training implemented on site is often far removed from science. The situation is exacerbated by staff shortages and economic problems faced by employers, as well as organisational difficulties due to increasing specialisation and the shift towards outpatient care. It has been proven that good structuring, accompanying seminars and established mentoring can accelerate and deepen the learning processes during advanced training [29]. Models for this exist within the competence-based curriculum General Medicine (Germen Society for General Medicine [30] that also addresses scientific competences as a teacher. It is also important to bear in mind that scientific know-how is increasingly required as a practical skill in order to cope with the flood of information and to be able to critically classify and verify it. In the course of increasing digitalisation, data must be validly recorded and stored at all levels of care and in all settings, and filtered and evaluated according to scientific rules. Only in this way can the physician roles of scholar and innovator, which are considered essential, be adequately fulfilled. Low-threshold examples of this are tumour boards and their outreach programmes, as well as research practice networks. Participation in registry studies during medical training and the use of electronic patient records for scientific evaluations also offer opportunities to acquire scientific competence not only as theoretical knowledge but also as practical competence.

A successful postgraduate training not only focuses core specialist competencies, but also introduces entrusted professional activities (EPT) for these core competencies. The implementation of new didactic elements such as simulation training and skills labs, the establishment of a feedback culture with training for those authorised to provide postgraduate training, and the adaptation of the examination procedure to test scientific competence and performance should also be part of this renewal process. Ultimately, the teaching and acquisition of scientific competence in postgraduate training can only take place between those authorised to provide and those undergoing training. In order to create a reliable framework for this, postgraduate medical education and its regulations must also be adapted and further developed to reflect the rapid progress of knowledge and changing conditions on the one hand, and to convey the medical role of the scholar as a teacher and learner on the other.

5.2 Expanding scientific competence in clinician scientist programmes

An excellent opportunity to acquire scientific competence in a well-structured form is offered by the intensive integration of scientific content within the framework of clinician scientist programmes (CSP). These programmes teach scientific skills within the framework of conducting one’s own research projects in parallel with clinical postgraduate training. Structured clinician scientist programmes thus support research-active physicians within the framework of residency training for medical specialists. The associated acquisition of scientific competence and the strengthening of scientific rigour in clinical training promote the iterative process from ‘bench to bedside’ and ‘bedside to bench’ and can thus also contribute indirectly to the optimisation of research ideas and treatment strategies. These programmes have now been established in Germany for over ten years, and almost every medical faculty now has its own programme [12], [31]. CSPs enable competence-based specialist training with a fixed amount of working time (“protected time”) for clinical studies and translational research [32]. In this way, they contribute to promoting the scientific skills of doctors interested in research (“clinician scientists”), supporting their scientific work and anchoring scientific competence in the postgraduate training of medical professionals.

Some of these programmes are coordinated between the implementing scientific institutions, mostly university hospitals, and the respective State Chambers of Physicians, thus enabling more extensive research periods to be recognised within postgraduate training. However, due to the principle of federalism, the successful integration of research activities into postgraduate training on a broad and reliable basis requires close cooperation between the training institution and the respective State Chambers of Physicians for each of these programmes. One problem here is the inconsistent recognition of research periods by the individual State Chambers of Physicians (see Figure 4 [Fig. 4]), which leads to a lack of motivation to participate in translational research within the framework of the CSP [33].

One of the first and currently largest CSPs in Germany is the programme run by the Berlin Institute of Health at Charité (BIH) and Charité – University Medicine Berlin [34]. The BIH Charité CSP is open to all topics and offers a competence-based, modular curriculum. The programme currently has around 170 active participants and over 250 alumni. They come from almost all clinical departments at Charité, which promotes and intensifies interdisciplinary networking. The ‘classic’ CSP supports doctors from the fourth year of their specialist training onwards with 50% ‘protected time’ for research. In addition, a Digital CSP prepares research-oriented physicians for the technological challenges of digital medicine. Specific junior (digital) CSPs are aimed at doctors in the first three years of their specialist training, with 20% ‘protected time’ for research, enabling them to embark on a combined clinical and scientific career. The Junior CSPs give doctors time to learn key scientific skills, thereby laying the foundation for their own research project.

In its pioneering role, the Berlin programme has set nationwide standards in terms of structure and quality and was designated a “best practice model” by the German Research Foundation (Deutsche Forschungsgesellschaft; DFG) in 2015 [12]. The long-standing duration (since 2011) and size of the Berlin programme allow for evaluations in terms of the compatibility/integration of clinical practice and research and the “outcome” of the programme: Data from the Berlin Medical Association (Ärztekammer Berlin) show that the combined clinical and scientific activities of the programme participants do not in any way impair their performance in the specialist examinations [35]. This objective assessment based on performance in the specialist examination corresponds with the personal assessments of programme participants who were surveyed as part of a scientific programme evaluation: With regard to the development of key medical competencies, the reduction in clinical hours as part of specialist training does not have a negative impact on specialist training. On the contrary: programme participants often believe that the integration of research into their everyday clinical work has enabled them to acquire valuable skills beyond the actual scope of the programme, which are particularly important for the successful translation of research results into clinical practice and vice versa [36].

5.3 Current status of teaching scientific skills in dental postgraduate education

In dentistry, there are significantly fewer specialist dental training programmes than in medicine: orthodontics, oral surgery, public health services, periodontology, general dentistry (the last two only in selected federal states), public health [37]. In 2005, the Science Council (Wissenschaftsrat) recommended expanding the areas of specialist dental training to include or link up with the scientific expertise of universities [38].

However, the proportion of specialist dentists remains low at 7.7% [39]. Various objections to expanding the areas of dental specialisation have been discussed, including the fear of a split in the dental profession. However, due to advances in dental science and medicine, there is a very clear trend towards specialisation among dentists, even without the implementation of new dental subspecialisations.

In addition to specialist dental training with a practical focus, numerous clearly structured and theoretical-scientific in-depth postgraduate training programmes have been developed in recent years, often designed as master’s programmes in cooperation with universities or specialisation programmes under the auspices of dental associations. These are not ‘vocational’ master’s programmes, but rather so-called ‘continuing education’ master’s programmes in cooperation with universities. These offer full-time or part-time courses that are completed over several years. Specialisation programmes offered by professional associations require at least 2–4 years of work in a specialist department of a university hospital or comparable training institution. As part of the programme, a specific catalogue of highly specialised services must be provided. Detailed patient documentation must be written in the form of case reports with scientifically reflected evidence (8–20 patients). Scientific activity through active participation in research projects, literature seminars, lecturing and the publication of 2–3 peer-reviewed articles in the specialist field (as first author and in the international area) must be demonstrated. A commission appointed by the professional association conducts a final examination. In order to retain the title of specialist, further qualification or postgraduate education must be demonstrated at regular intervals. Due to the high requirements of the scientific and practical training in the specialisation programmes of the professional associations, these qualifications are recognised as equivalent to those of a specialist dentist with regard to salary an academic career options.

6 Maintaining scientific competence in continuing medical education

6.1 Requirement and current status of maintaining scientific competence in human medicine

It is necessary to focus more on basic scientific principles and new developments in this area in continuing medical education (CME), because scientific competence is becoming increasingly important in everyday healthcare and is essential in order to keep pace with the ever-faster growth of knowledge. Factual knowledge is playing a decreasing role, because the internet and artificial intelligence allow for rapid research and decision support. To this end, all medical professionals must be able to optimally assess and use these sources of information. Scientific competence is more important than ever and is one of the basics. Methods and access routes are also changing in this area, making continuous training necessary. However, this is currently only happening sporadically and in an unstructured manner. In the field of general medicine, the Institute for Advanced education in General Practice (Institut für hausärztliche Fortbildung) – a non-profit subsidiary of the Association of General Practitioners (Hausärztinnen- und Hausärzteverband; HÄV) – in close cooperation with the Scientific Society for General Medicine and Family Medicine (Deutsche Gesellschaft für Allgemeinmedizin und Familienmedizin; DEGAM) offers a comprehensive range of services for maintaining and developing GP skills, which also includes scientific components (https://www.ihf-fobi.de/; [40]). The continuing medical education academies of the State Chambers of Physicians also offer individual events in this field, but there is room for improvement. For medicine to progress as a scientific discipline, it is necessary for data and findings from everyday healthcare practice to be scientifically processed and classified (‘knowledge-generating practice’) – not only in university hospitals, but across the board.

To this end, a research network for general practitioners has been established throughout Germany, DEGAM ForNet [41], in which more than 1,000 doctor’s offices are already integrated and receive appropriate training and offers for research cooperation.

6.2 Current status of scientific competence in dentistry

In continuing education, dentistry also has an obligation, in accordance with §2 of the model professional code of conduct (Musterberufsordnung) of BZÄK (Bundeszahnärztekammer), for every dentist to constantly adapt his or her knowledge to the current state of dental science [42]. The Academy of Practice and Science (Akademie Praxis und Wissenschaft; APW) was founded in 1974 under the umbrella of the German Society of Dentistry and Oral Medicine (Deutschen Gesellschaft für Zahn-, Mund- und Kieferheilkunde; DGZMK) as an independent and neutral institution for high-quality and scientifically demanding continuing dental training. The aim was and is to transfer knowledge from science to practice by offering structured training courses. In addition to individual training courses, the APW offers curricula that build on each other, providing scientific and practical in-depth knowledge of a specific topic over one to two years in several modules lasting several days. Here, final examinations are also held regularly for quality assurance purposes. The assessment based on ECTS credits enables the international transfer of qualifications. In addition, the training courses offered by the academies of the dental associations, which are self-governing, provide economically independent training courses with a high scientific relevance. Within this system, practical skills and theoretical knowledge are taught on a scientific basis. However, the cultivation and development of specific scientific skills within the framework of continuing dental education is significantly less extensive and, as in medicine, requires targeted promotion and integration into the content of the advanced education curriculum.

7 Discussion

Some fundamentals of scientific thinking and action are already the subject of teaching and examinations in the current pre-clinical and clinical courses of medical school curricula. The Mannheim example shows that the relevant courses can be combined into a longitudinal curriculum, at the end of which students write their own scientific thesis. Other faculties have also taken similar initiatives. Even if a comprehensive reform of the Licensing Regulations for Medical Doctors (ÄApprO) is still pending, it is possible for faculties to establish a structured longitudinal curriculum for scientific competence under the current legal framework.

One way of conveying the importance of scientific skills to students, including for everyday clinical practice, is to familiarise them early with clinical practice guidelines. This is precisely the aim of the updated competence-oriented subject catalogue [43]. The German Society for Gastroenterology, Digestive and Metabolic Diseases (DGVS) has also explicitly set itself the task of contributing to the reception and reflection of clinical practice guidelines during medical school training by identifying learning objectives in these guidelines that are suitable for students [44]. This is an important prerequisite for their implementation in everyday clinical practice and teaches students to base their medical actions on the principles of evidence-based medicine at an early stage. Figure 5 [Fig. 5] summarises these ideas.

8 Conclusion

Scientific thinking and action are among the core competencies of medical and dental practice. With the ubiquitous availability of AI-based search engines, detailed factual knowledge is taking a back seat to the ability to critically evaluate available data and information and apply it to specific patient care. This ability must be systematically acquired during university studies by incorporating theoretical and practical experience with primary data generation (clinical research) and systematic literature searches for clinical and scientific research questions and evaluation and integration of evidence in for of e.g. meta-analyses (evidence-based medicine). This should be part of all curricula. This is laid out in the role of physicians as scholars in the national competence-based learning objective catalogues for medicine and dentistry (NKLM, NKLZ), which are integrated into the new draft Licensing Regulations for Doctors (ÄApprO) but have not yet been implemented across the board in medicine. This role of physicians must be further expanded in residency and continuing medical education programmes. The basic scientific and methodological training of its graduates is also essential for the continued existence of medicine and dentistry as academic disciplines. The corresponding AWMF’s recommendations for a future-proof healthcare system are summarised in Table 4 [Tab. 4].

Notes

Acknowledgements

We would like to thank the speakers and participants in the panel discussion at the Berlin Forum, Thomas Krieg, Robert Thimme and Frank Wissing, as well as all those who took part in the floor discussions for their contributions to this article.

Competing interests

The authors declare that they have no competing interests.

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