Curricular representation of neurogastroenterology: A survey among medical students in Germany

Neurogastroenterological disorders (NGDs) are highly prevalent and substantially impact patients' quality of life. Effective treatment of NGDs depends on the competence and training of medical caregivers. Students' perceived competence in neurogastroenterology and its place in medical school curricula are assessed in this study.


| INTRODUC TI ON
Neurogastroenterology addresses a broad spectrum of various medical conditions including disorders of gut-brain interaction (DGBIs) and enteric neuropathies.Collectively, these neurogastroenterological disorders (NGDs) or disorders of gut-brain interaction are based on complex pathophysiological mechanisms and involve a biopsychosocial etiology.The spectrum of NGDs includes entities with a broad range of symptoms and prevalences, for example, irritable bowel syndrome (IBS), dyspepsia, gastroesophageal reflux disease (GERD), and achalasia.[3][4] Considering the prevalence of IBS alone is around 5% in the German population, it seems unavoidable that medical caregivers of all specialties will have contact to patients suffering from at least one NGD on a regular basis. 5Unfortunately, a previous empirical study indicated that "US family practitioners had attitudes about patients with IBS and lack of knowledge about some important aspects of the disorder that could interfere with patient care." 6Similar findings were reported for postgraduate doctors in the United Kingdom and Saudi Arabia, suggesting that it is persistent throughout different socio-cultural contexts. 7,8As was shown in a recent survey among young gastroenterologists in the United States, "unwillingness and discomfort" related to NGD are already reported at an early stage of postgraduate training even among future gastroenterologists. 9 In Germany, an analysis of health insurance data of more than 8 million individuals indicated that "Patients with IBS […] are likely not receiving sufficient diagnostic evaluation in conformity with the relevant guidelines." 1 Thus, there is a large potential for improving symptom management in this growing patient population.
An intuitive approach to address these needs by strengthening caregivers' competencies are curricular reforms in medical education.Teaching competencies with a focus on the epidemiologically most relevant medical conditions is an important element of this process.Learning objectives are conceptionally central for competencybased curricula.As a blueprint for the nationwide convergence of medical school curricula in Germany, the first version of the national catalogue of competence based learning objectives (Nationaler Kompetenzbasierter Lernzielkatalog Medizin, NKLM) for undergraduate medical education was published in 2015. 10The NKLM will be adapted continuously and is intended to serve as a consistent mandatory framework for all medical faculties in Germany, the so-called nationwide "core curriculum."However, medical students, the actual target group, are not consistently involved at all stages of curricular mapping, development, and implementation, although the participation of students at different steps of curricular development (i.e., target needs assessment, implementation, and evaluation/feedback) is highly recommended. 11 our best knowledge, the curricular representation of NGDs and NGD-related competencies of undergraduate medical students have not yet been the subject of published investigations, except for a recent study in which an almost complete neglect of NGD content was found in an analysis of the UK Medical Licensing Assessment content map. 8An earlier study aimed to survey the gastroenterology curriculum of 17 Canadian medical schools.The information analyzed in this study was, however, obtained from the local curriculum coordinators only.While medical conditions, for instance, IBS, were reported to be part of the curriculum in all institutions, less than half of the curricula included food intolerances or pediatric gastrointestinal diseases. 12Students' competencies and perspective were however, not addressed in both studies.
The aim of the current study is to elucidate the representation of NGDs in the curricula of five medical schools in Germany from the medical students' perspective.Using an online survey, we assessed the attitudes of medical students toward NGDs, their perception of curricular offers regarding neurogastroenterology, and their subjective familiarity with NGDs.

| ME THODS
The survey items were developed by a task force of the German Society for Neurogastroenterology and Motility (DGNM).After agreement had been reached about the items and scales, five students from the University Medical Center of Rostock were asked to complete the survey and give feedback about the required time and points needing clarification.Following the final refinement of items, this survey was approved by the local ethics committee of the Rostock University Medical Center (No.A 2021-0058).
Subsequently, local approvals were given by the students' dean's office in Tübingen and Munich (Technical University) and by students' affairs councils in Dresden and Heidelberg.Anonymous data were collected online using the platform www.surve yhero.com.
The participants could complete the survey using a link that was distributed to medical students from the local dean's office or the student body of the respective medical school.The surveys were started between March and July 2021 and could be completed within 8 weeks.

Key points
• Although neurogastroenterological disorders are highly prevalent, there is insufficient data about their representation in medical school curricula.
• In a digital survey among medical students from five universities in Germany, self-ratings of competence regarding irritable bowel syndrome (IBS), gastroesophageal reflux disease, achalasia and other chronic medical conditions were assessed.
• Compared to other chronic conditions as hypertension, migraine or ulcerative colitis, students report low levels of subjective competence in handling NGDs, especially IBS.
The questionnaire (provided as Appendix S1) consisted of 14 items that addressed biographic data and attitudes and three questions that asked the participants to rate their competence in basic mechanisms, diagnosis, and treatment, respectively, for six chronic medical conditions.To obtain an internal calibration of competence rating, we chose chronic diseases from other clinical specialties and with roughly matched epidemiological characteristics.
The final selection included IBS, GERD, and achalasia to represent classic NGDs and references for chronic diseases within (ulcerative colitis, UC) and beyond (migraine, hypertension) the field of gastroenterology.
Data were stored and processed using Microsoft Excel 365 (Microsoft).For statistical analysis and graphical presentation,

| Sample characteristics
The total number of invited participants was 1740.Of these, 231 participated in this study (response rate: 13.3%).Only completed surveys were included for analysis (n = 220).In Table 1, the distribution of participants is given together with demographic information and information on their educational background.Sex, mean age, and study duration of participants differed between the local subgroups with the small sample (Heidelberg) showing the largest deviations.

| Neurogastroenterology in medical curricula
In total, 39% of all students reported that the field of neurogastroenterology had been addressed in their local curricula (Table 1).
Moreover, the vast majority (n = 217; 99%) stated that single aspects of NGDs had been outlined by at least one clinical specialty (Figure 1A,B).Eighty two percent of students support an expansion of NGD-contents in the regular curriculum and 70% in terms of elective offers, respectively (Figure 1D).Only 17% stated that neurogastroenterology is not relevant in clinical medicine (Figure 1E).

| Self-rated competencies regarding neurogastroenterological disorders
All participants were asked to estimate their competence regarding basic mechanisms, diagnosis, and treatment of six selected chronic medical conditions on a scale between zero (no competence) and 100 (full competence).To assess potential local differences, the mean values of cumulated competence ratings over all competence categories, disease entities, and participants were compared between institutions (Figure 2A).Students from Dresden and Rostock stated almost identical levels (Dresden: 60.3; 95% CI: 58.8-61.8;Rostock: 60.2; 95% CI: 58.2-62.3),which were both lower than the ratings of students from Munich and Tübingen.The two latter were again similar among each other (Munich: median: 69.3; 95% CI: 67.5-71.1;Tübingen: median: 67.9 95% CI: 65.7-70.1).The small sample from Heidelberg reported the lowest ratings (57.1; 95% CI: 52.4-61.8).One-way-ANOVA confirmed the global difference between institutions (p < 0.001) and specific differences between single institutions were confirmed using Dunn's method for post-hoc testing as depicted in Figure 2B.Students' ratings on their subjective competency regarding the basic mechanisms, the diagnostic approach and the treatment of the selected chronic disease entities are given in Figure 3A-C.

TA B L E 1
Irrespective of the surveyed category and the participant's medical school, students' competency ratings were highest for hypertension and GERD and lowest for IBS and achalasia.The significance of the differences between perceived competency in dealing with certain diseases was confirmed in global one-way-ANOVA (p < 0.001) and could be attributed to differences between single entities in Dunn's post-test as shown in Figure 3D-F.
The participants' competence ratings for single disease entities were correlated significantly within and between the three distinguished categories: Between-categories correlations of competence regarding specific diseases (e.g., diagnosing and treating migraine) were generally stronger than within-category ratings between the different diseases (e.g., basic mechanisms of migraine and achalasia).
The arithmetic mean of coefficients (Pearson) was 0.37 ± 0.10 for intra-, and 0.62 ± 0.07 for between-category correlations.Students' competence ratings for ulcerative colitis, migraine, hypertension, or GERD were weakly correlated with those for achalasia or IBS.
In the upper-right half of Figure 4, this is visualized by the rather dark color of the lines for achalasia (horizontal) and IBS (vertical).In contrast, competence ratings between ulcerative colitis, migraine, hypertension or GERD were correlated stronger.The difference in correlation coefficients was highly significant (mean correlation between competencies in IBS and achalasia and all other diseases: Whereas the participants' sex had no effect on self-reported competencies, students with previous experience in a medical profession surprisingly gave slightly lower competence ratings regarding "diagnosis" and "treatment" (diagnosis: with previous experience: 64.0, 95% CI: 60.9-67.1;w/o: 68.6, 95% CI: 66.9-70.

| Students' view on curricular representation of neurogastroenterology
Whether or not students could identify neurogastroenterology within their curriculum affected students' subjective competences in gastroenterological diseases.For the sake of clarity, only competence regarding "diagnosis" is reported here: (Figure 5): Ratings were significantly higher for achalasia (p < 0.0001), ulcerative colitis (p = 0.02), and for IBS (p < 0.0001), but not for migraine (p = 0.077) and hypertension (p = 0.83).For GERD, significance was missed narrowly (p = 0.051).In contrast, there were no significant differences of competence scores in relation to whether or not students had been offered elective courses on NGDs.

| DISCUSS ION
This multi-centered survey shows that advanced German medical students report a significantly lower confidence concerning the basic mechanisms, diagnosis, and treatment of IBS compared with any other medical condition that was part of this survey.In contrast, they report feeling confident regarding migraine, hypertension, GERD, and ulcerative colitis.This is remarkable since the prevalence of these conditions is likewise or even far less prevalent than that of IBS.For both migraine and IBS, estimates of the prevalence are in a similar range and the underlying mechanisms are complex and in parts unknown. 13Nevertheless, students feel more competent with migraine than with IBS.Ulcerative colitis, on the other hand, is far less prevalent and can be considered to be at least as complex regarding pathophysiology, diagnosis, and treatment as IBS and migraine.Paradoxically, students were more confident regarding their competence in dealing with ulcerative colitis, despite the outstanding dynamics and complexity in this field, a finding that was also reported among U.S. medical students. 14,15The large competence gap for IBS can therefore neither be explained by differences in epidemiology nor by differing efforts to achieve competence in dealing with this disorder on the level that is relevant to students.We thus hypothesize that a curricular underrepresentation of IBS contributes to the lack of perceived competence to IBS and possibly also to other NGDs, especially achalasia.
In line with this, a second finding is that despite their high prevalence and relevance for the patients' quality of life, some neurogastroenterological entities seem to be insufficiently represented in German medical curricula.This is supported not only by the students' direct responses on questions regarding desired changes in teaching but also by an analysis of intra-category ratings: Within the categories (basic mechanisms, diagnosis, and treatment), scores were well-correlated between hypertension, migraine, ulcerative colitis, and GERD.
Conceivably, this reflects a general perception of the single participant's self-concept of meeting (or missing) the set learning targets (i.e., the general competence as perceived by the student).In contrast, ratings for achalasia and IBS were not related to this general competence, thereby reflecting their underdog position in current curricula.
Respondents who recalled that NGDs had been part of their academic curriculum gave higher competence ratings than those who denied or could not remember teaching lessons in this field.This indicates that low competence regarding NGDs is not set in stone: addressing and highlighting these disorders can help students to gain confidence in their clinical competencies and might have beneficial effects on later patient care.7][18] Effective educational measures for improving learners' competence and attitudes related to NGD do exist and have been evaluated thoroughly. 17,19,20Nevertheless, the relevant contents, although formally included in undergraduate and postgraduate gastroenterology curricula, seem to be covered with insufficient depth and detail, e.g.without defined learning targets and practical training for motility diagnostics or communication skills. 8A possible explanation for this might be the low number of academic researchers and professors with a focus on NGD that has only recently been reported also for France and the Netherlands. 17 This study has some limitations: First, the populations of participants came from faculties with differing models of teaching and curricular organization.Surprisingly, these differences did not result in the expected differences in responses: Although Rostock offers a traditional curriculum with separated preclinical and clinical sections of studying and discipline-centered teaching, ratings in all categories were highly similar to that from Dresden, where students go through a curriculum that has undergone significant reforms to establish a "student-centered, interdisciplinary, and integrative curriculum." 21spite these large differences in curricula, students from both institutions reported almost identical levels of competence.
Although it would be desirable to consider the local curricula and their correlation with students' perceptions with more detail, we have decided to completely focus on the learners' perspective is this work.As a limitation, this implies that students' responses are confounded by recall bias: the mere fact that a student could not remember teaching does not mean that none was offered.For the future attitudes and learning of the advanced medical students that participated in this study, however, it is only their subjective present perception that is relevant and was thus chosen as the "end point" of medical education in this study.Obtaining valid information on the local curricula and the practical teaching situation is a complex and effortful task and may be the subject of future studies in the context of the ongoing process of "curricular mapping" at medical schools in Germany and worldwide.
Another limitation of this study is the reliance on students' self-assessment: "Subjective" competence is the central readout used in this work.Although its definition is extremely controversial, 22 for the sake of practicability we assumed that participants would define "competence" as having the knowledge and skills required for understanding and handling medical conditions they are faced with.
4][25][26] Therefore, the results of this study are not intended to judge or compare the achieved competence of participants.8][29] The lack of confidence in students' self-perceived competence to deal with a highly prevalent disorder thus raises serious concerns regarding the medical care for these patients and be Finally, the overall response rate of 13.3% achieved with this online survey is lower than rates that are seen with other surveys, especially when participants have known personal relations to the subject of the survey. 31Nevertheless, in surveys with a sample size in the range of our study, response rates of 5%-10% have been shown to give reliable results in the context of educational research. 32

| CON CLUS ION
Taken together, this study gives evidence for an insufficient representation of epidemiologically and practically relevant medical conditions in German medical curricula from the students' perspective.
It underlines the need to enforce the development of interdisciplinary curricula to improve the competence of future doctors in handling chronic medical conditions of great socioeconomic impact.
Empirical research focused on the alignment of the status quo of current curricula with epidemiological and clinical demands is still rare.Evidence for underrepresentation of NGD in medical education has been reported for the United Kingdom based on an analysis of regulatory documents. 8Multi-center assessments involving different stakeholders may improve the quality of curricular development and political decision-making in the interest of patients.
For the highly prevalent NGD, teaching the basic mechanisms and diagnostics of motility and the biopsychosocial basis of the gutbrain axis are effective in increasing NGD-related competencies and improving attitudes of undergraduate medical students and young gastroenterologists.From our point of view, the findings presented here may be useful to accompany and guide the ongoing process of curricular reform in medical schools with the aim to close the existing gap in high-quality medical care for patients suffering from NGD.

OriginPro 8 .
1 (OriginLab), SigmaPlot 10.0 (Systat Software Inc.), and Microsoft PowerPoint 365 were used.Statistical testing for comparisons between groups was done using analysis of variance (ANOVA) algorithms provided by SigmaPlot 10.The Kruskal-Wallis test was applied for non-normally distributed samples.Two-way repeated measures ANOVA was applied to evaluate which factors caused differences in respondents' competence ratings.The applied posttests are stated in the text.Pearson's correlation coefficients with Bonferroni corrections for multiple testing were calculated to describe intra-individual associations of competence ratings.

F I G U R E 1
Students' reported view on curricular implementation of neurogastroenterology in medical school curricula.(A) Curricular coverage of neurogastroenterological disorders by curricular teaching offers of clinical disciplines (multiple selections were allowed) (B) Cumulative number of disciplines that covered neurogastroenterological disorders.(C-E) Students' multiple-choice responses on the desired extent of regular (C) or elective curricular offers in neurogastroenterology (D) and on its clinical relevance (E).F I G U R E 2Subjective competence of all participating medical students pooled over all disease entities included in this survey and over all categories of competence.In (A) horizontal lines in boxes represent median values, squares in boxes depict arithmetic means.Boxes represent 25-75 percentiles, Whiskers 10-90 percentiles.Dots represent responses of all participants for all types of competencies.In (B) sterisks depict a statistically significant post-test, "n.s." is given for non-significant pairwise comparisons.0.32 ± 0.09; mean correlation between competencies in all other diseases: 0.44 ± 0.09; p < 0.001).

F I G U R E 3
Subjective competence of all participating medical students regarding the basic mechanisms (A,D), the process of diagnosing (B,E), and the treatment (C, F) of selected chronic medical conditions including neurogastroenterological disorders.In A-C, dots represent the responses of all participants for the respective competency, horizontal lines in boxes represent median values, and squares in boxes depict arithmetic means.Boxes represent 25-75, Whiskers 10-90 percentiles.In D-F, asterisks depict a statistically significant post-test, "n.s." is given for non-significance in pairwise comparisons.

F I G U R E 4
Correlations of subjective competencies of all participating medical students regarding the three categories and single diseases.Color codes above the diagonal autocorrelation line display the value of Pearson's correlation coefficient, those below display the significance of the respective correlation after Bonferroni adjustment for multiple comparisons.Significance is stated for log10(p) <−1.3, which equals p < 0.05.a causative factor in the problems and shortcomings of medical care for IBS patients in Germany that have been documented on a large database.1,30 Survey sample distribution, biographic data, and perception of coverage of neurogastroenterological disorder by the local curriculum.
a Applies to clerkships in institutions with focus on gastroenterology, digestive disorders, or eating disorders.