Hepatobiliary Surgery Department, Nantong University Hospital, Nantong, China Chang Ren’an Hepatobiliary Surgery Department, Nantong University Hospital, Nantong, China Chang Ren’an Hepatobiliary Surgery Department, Nantong University Hospital, Nantong, China I participated in the German-Chinese Science and Technology Exchange Foundation project, and went to Germany for a 3-month clinical training from June 2015 to August 2015, with the financial support of Jiangsu Provincial Department of Health and Bureau of Foreign Affairs. During the nearly three months of study, I deeply appreciate the gap between our medical level as a developing country and that of developed countries, and also feel the responsibility and burden as a surgeon. 1. beautiful port city, harmonious medical environment We are in the port city of Hamburg, the second largest city in Germany, in the northwest of Germany, large green areas and numerous canals make Hamburg the most green city in Germany. Hamburg’s full name is Freieund Hansestadt Hamburg, or HH for short, and it is also the seventh largest city in the European Union. The port of Hamburg is the number one port in Germany and is known as Germany’s gateway to the world. Hamburg’s city flag is the gateway to the city. Hamburg has many rivers and bridges, and since its foundation there have been about 2,500 bridges, more than the bridges of the water cities of Venice, Amsterdam and London combined. The accommodation arranged by the Foundation is in the small town of Elbgaustrasse, which is well-equipped and quiet. I studied at the Center for Hepatobiliary Surgery and Transplantation of the University Hospital Eppendorf (UKE) in Hamburg. The medical center is located 5 km from the city center. The hospital was founded in 1823 and has grown into the largest medical institution and research institute in Hamburg with more than 15 research centers, 81 departments, 80 interdisciplinary branches and clinics. The new hospital building is 200 meters long and 120 meters wide, with a construction area of 8,000 square meters, with 1,500 beds, 6 floors, and a cost of 188 million Euros. The new hospital has 3500 rooms, 16 operating rooms and 60 intensive care units, making it one of the most modern hospitals in Europe. The exterior of the hospital is very beautiful, with green trees and blue skies, and a large park across the street from the hospital, all green. The whole hospital is very quiet, sporadic vehicles parked inside the hospital, no bustling crowd. It was only after entering the hospital that I saw that everything was running in an orderly manner. There are no patients’ families here except for the outpatient clinic, and even for surgery, no family members can be seen coming. The outpatient clinics are all by appointment, unlike in China where there is a sea of people at the entrance of the outpatient clinics and operating rooms, and it is difficult for doctors to move around. The clinical departments in Germany have a professorial system, with only one professor in each department, who is fully responsible for the administrative and operational work of the department. The professor has a secretary to assist in the day-to-day affairs. Professors lead the work of attending physicians, residents and trainees. The Department of Liver and Organ Transplantation Surgery, where I studied, is the second largest transplantation center in Europe and focuses on the clinical treatment and research of liver cancer and liver surgery related diseases. We perform a variety of liver resections, liver transplants, kidney transplants and pancreas transplants. Prof. Nashan of the Department of Hepatobiliary Surgery leads the entire Hepatobiliary Surgery and Transplantation Center, conducting clinical research on liver tumors and basic research on transplantation immune rejection, publishing hundreds of papers in professional journals and being a leader in Europe in both clinical and academic aspects. Dr. Lutz Fischer is the deputy head of the department and is responsible for most of the clinical work and surgeries, Dr. Lijun is a German-Chinese doctor and directly supervises us, which facilitates our learning and communication. The work of German doctors is not less intense than that of Chinese doctors, but of course unlike Chinese doctors, they don’t need to waste a lot of time on writing medical records, explaining conditions, typing applications, and other things that have little to do with medicine. Germany has free medical care, and the cost of medical care is already covered by taxpayers, so doctors can focus all their energy on medical care. Doctors in Germany are not fixed to any hospital and are quite mobile. The differences between hospitals in Germany are not as pronounced as in China, where large hospitals are crowded with patients and small hospitals are crowded. Germany has a good referral system and physician training system. The physician training system allows for less variation in the level of trained practitioners, all of whom are formally trained, allowing patients to fully trust their family physicians and community physicians. Patients usually go to their family doctors or community doctors first and are referred to higher hospitals only when needed, avoiding waste of medical resources and over-concentration of patients. At Hamburg University Hospital, there are about 50 surgeries per day. Doctors arrive at 7:30 a.m. sharp to start the morning meeting, and all doctors, as well as trainees and interns, gather in the meeting room to discuss the previous day’s surgeries and the day’s surgeries. The meeting is usually chaired by Prof. Nashan. The junior doctors or assistants first report on their conditions, the surgeons comment, other doctors add to them, and Prof. Nashan makes concluding remarks. The doctors are filled with advanced digital workstations, and the computers in the conference room can quickly retrieve information and project it on a large screen. The resident will pull up the patient’s information and images and project them, present the condition and treatment plan, and the senior doctor will keep asking questions and suggesting options, and the discussion is very specific and not formal. After the meeting, the general professor and several deputy directors stayed behind to discuss some important issues. The hospital has no fence, the gate is grand and conspicuous, everything is in order, there are no crowds and the traffic at the entrance is smooth. 2. Medical insurance: wide coverage and high level of universal health insurance. Germany is a country with universal health insurance: 90% of the citizens participate in the compulsory national health insurance, and less than 10% of the people, in order to get better medical services, buy private health insurance. The difference between the two is that the relatively wealthy people who have private insurance can get better services during the treatment, such as a single room and a specialist of their choice for surgery. The quality of care is the same throughout. 3. The doctor-patient relationship: life depends on life. During my study in Germany, I heard about many cases of injury to doctors in China. This prompted me to take a closer look at the doctor-patient relationship in Germany. Patients in Germany are very relaxed, and seeing a doctor is like making a friend. The first thing a doctor does is to shake hands with the patient and say hello. Compared with the frequent cases of injury to doctors and protective medical measures in China, this kind of doctor-patient relationship is really harmonious. This is why outpatient and ward work is so efficient. Due to the sound social security, doctors do not need to consider the cost at all when treating patients, so that everything is done in accordance with the condition. Doctors do not have tasks or examinations, so they are not under as much pressure as in our country. Of course, German doctors spend a lot of energy on researching their practice. In Germany, the state provides basic medical insurance, citizens do not need to pay for their own medical care, but if you want to see a professor for surgery, you need to buy commercial medical insurance, and the insurance company will settle the bill with the hospital. 4. doctor rank: German hospital doctor rank is not the same as the United States, but has similarities with China. There is only one director of the department, who is the only person in charge of the department and has the highest authority in the department, usually a professor. No other doctor, no matter how senior, can be called a professor. Under the professor, there are mid-level doctors (called OberArtz in German), general specialists (called Artz in German), and assistant doctors, which are equivalent to doctors-in-training in China, with a 2-year training period, not considered official. The morning meeting of the department starts at 7:30 a.m. every weekday, with the professor in the middle, the two deputy directors next to him, the attending physicians in the row on the right, and the residents in the row on the left. The length of the morning meeting is not fixed, sometimes twenty minutes, sometimes five minutes, the professor usually arrives on time, and then closes the door and starts. The advanced physicians and interns sit in the back row. After the shift is over, the senior physicians get together to discuss some issues. The learners usually go straight to the surgery tour. The operating room porters are also very specialized. This patient was post second liver transplant and his vitals were quite unstable. Also on a ventilator, hemodialysis, etc., with several various tubes in his body, the workers handled it carefully and transferred it safely. At the completion of the lumpectomy, multiple monitors facilitated multi-angle viewing by the surgical team and off-stage personnel, and the operating room had natural lighting, a lumpectomy gallbladder two people were sufficient. The German surgeons hardly eat lunch and are very energetic and dedicated. The layout of the operating room is scientific, all kinds of instruments and surgical supplies are well prepared, and patient management is humane. Junli, a Chinese doctor, completed a liver surgery and pointed to the liver specimen to explain to us. Fortunately, there was Dr. Li, otherwise there was a big obstacle in our communication with the German doctors. The German doctor’s working cell phone is so simple, Nokia, which has been rarely seen in China. Before the doctors went on stage, they uniformly put their cell phones and carry-on bags on this shelf, and their badges were also clipped on it, in an orderly manner. No one went to work to play with their smartphones, all minds were devoted to their work. The large liver resection specimen is an enlarged right hemicolectomy specimen. The work is done with the best tools. Electric knife, electric scissors, bipolar electrocoagulation, ultrasonic knife, CUSA can not be missing one, just the pull hook is a series, and each pull hook are wrapped with gauze cover, reduce tissue damage, reduce reflection, next to the rinse machine, under the power connected to keep the rinse water constant temperature, as rigorous as this. Before each liver resection, we have to use intraoperative ultrasound to see the vascular alignment to make sure we have a good idea. And after the liver transplant vessels are anastomosed, they also repeatedly use intraoperative ultrasound to understand the anastomotic blood flow, rigorous and meticulous. The professional specimen retrieval company follows the process to retrieve the specimen. First, they measure, take pictures, then take the specimen, and finally fix it and send it for examination. All of them use gauze pads during the operation and hang them on the shelf after use, so it is good to count them at a glance, not easy to make mistakes and convenient to operate, and the real work is seen in the details. I participated in the multidisciplinary consultation (MDT) of liver tumor, and the departments of hepatobiliary surgery, oncology and imaging held multidisciplinary consultation on every Friday afternoon, each expressing their own opinions, all starting from obtaining the best treatment effect. The three-month study in Germany was very rewarding. Prof. Nashan took a photo with me and invited me to come to China to lecture at an appropriate time. The three-month trip to Germany was busy and fulfilling, making me feel that the time passed too fast and there were too many good memories. The trip gave me an in-depth understanding of German medical culture and medical level, and a first-hand experience of the life of German people. At the same time, I had an in-depth field understanding of the history and culture, religious beliefs, scientific civilization and political system of Germany and Europe. Through the study, I have broadened my horizons and enriched my experience, both professionally and personally. Once again, I would like to thank the German-Chinese Foundation for Scientific and Technological Exchange, the Jiangsu Provincial Health Department and the Bureau of Foreign Affairs and the leadership of our hospital for their great support. This study has helped me a lot and is a valuable lesson in my life experience.