With the strong support from the hospital leaders, I started my three-month study at Soest Hospital in Germany in December 2019, and I felt quite a lot, not only learning professional skills, improve professional English, and broaden their horizons. As the saying goes, ”Learn as much as you can and do all you can”, how to put the learned knowledge into the clinical practice is the subject I have been pursuing. The training experience in Germany is also a memory that I should treasure in my life. Now I will report on what I have learned in Germany.
I. Perfect medical service system
Like eating and dressing, medical care is a basic need of a person. However, solving medical problems is much more difficult than eating and drinking. The reason is that medical resources are limited and the needs of patients are almost "infinite". Germany is one of the few countries in the world, which most people are satisfied with the medical system (58%) or very satisfied (18%). Reasonable medical structure, proper government supervision, strict doctor management, convenient medical treatment, etc. should be the reason for the well-received German medical system.
1. 1 Fair medical insurance
Germany is the earliest country in the world to establish a social security system. It has always adhered to the implementation of a compulsory social insurance system, which is also reflected in medical insurance. Germany implements a compulsory medical insurance system based on social health insurance, supplemented with commercial insurance.
German national law stipulates that employees with an annual salary of less than 57,000 euros must participate in "statutory medical insurance", which covers nearly 90% of Germany's population. Statutory insurance premiums account for about 15% of wages, and individuals and employers each pay 50%. If the income is more than 57 thousand euros, you can freely choose a statutory insurance company or a private medical insurance company (10% of the German private insurance population).
The German government subsidizes statutory medical insurance companies by 15 billion euros from taxpayer pockets each year, but this only accounts for 5% of the 300 billion euros of the medical industry. Therefore, the German medical system is not a welfare because the state does not pay much money. The basic principles of the German medical system are: The basic principles of the German medical system are: do your best, distribute on demand, and everyone is equal.Rich people pay more, and lower incomes pay less, but they put money in one basket. Patients use the medical insurance card to get money in the basket as needed. No matter what your income or status is, treat it equally.
The composition of German hospitals is mainly public hospitals, church hospitals and private hospitals. However, regardless of the hospital in which the patient is hospitalized, if he enjoys "statutory medical insurance", all hospitalization and treatment expenses, including meals during the hospitalization period, will not be paid for by himself.
1.2 Strict medical personnel training
German high school graduates are eligible to enroll in universities, and there are no quota restrictions on almost all majors. However, medical schools are highly competitive. High school graduates must register for application at the "German National Medical School Admissions Office", and only 10% of the best scores are expected to study medicine. The medical school has a six-year education system and strict assessment. If you want to get a diploma, you have to study hard.
"Practice is more important than theory" is the characteristic of a doctor's profession. Although graduating from the medical school has obtained the "permit to practice medicine", it is only allowed to contact the patient, can not prescribe,but only treats the patient under the supervision of a senior doctor. The "German Doctor Regulations" stipulates that all medical school graduates must also complete a "five-year practice plan": 1) work in a qualified hospital for at least three years. 2) Work in different clinics for one to two years. 3) Participate in a certain number of medical lectures. 4) Independently complete relevant professional auxiliary inspections, write inspection reports, and reach a certain number. After the "five-year plan" is completed, you will be eligible to apply for a professional exam (equivalent to the attending physician in China). Attending physician is eligible to apply for a clinical license. The "license" means the doctor get a lifelong job. Whether you open your own clinic or cooperate with others, you can get treatment and inspection fees from the national statutory insurance company.
However, if you want to engage in cardiovascular interventional surgery, you still need to receive 3 years of training in cardiovascular interventional skills after obtaining the qualification of cardiologist, and you can only perform independent operations after passing the assessment.
German hospitals generally sign work contracts with graduates for only three years, with a maximum of five years. After the contract expired, they all left the hospital and gave up their "seats" to new graduates. In addition to treating inpatients and engaging in scientific research tasks, German hospitals are also an important base for training young doctors.It is far-sighted to take out the best hospitals in Germany to train young doctors.
Medicine is one of the cutting-edge scientific research fields in the world. Therefore, German doctors must learn for life. All doctors in clinics and hospitals (regardless of age and position) will take 250 hours of "classes" or "academic lectures" every five years to learn about new academic progress and new treatments for updating expertise.
1.3 The hospital / clinic division of labor is clear
Unlike all Chinese hospitals, Soest City Hospital does not have an outpatient department. Although some German hospitals have outpatient departments, a doctor in the morning usually only handles two or three patients, and patients are admitted on an appointment basis.
Various clinics located in the streets and villages are the first choice for treatment. Many hospitals even rent idle real estate to doctors with "clinic license" to open outpatient clinics in hospitals (however, hospitals are not involved in management, and outpatient clinics are not allowed to display hospital signboards).
Germans usually go to a fixed clinic, and first listen to the views of a family doctor. Family doctors are generally general practitioners or physicians. The patient was referred when the condition was complex and required further examinations by other specialists. As long as there are departments in the hospital, there are corresponding clinics in the society: internal medicine, surgery, gynecology, pediatrics, E.N.T, ophthalmology, rehabilitation and physiotherapy. There are also enough laboratories and radiology services (CT, MRI, etc.) in the society to provide services. The test results and test reports, as well as the diagnostic results of other specialist clinics, will be notified in writing to the family doctors or clinic doctors who issued the examination request form.
If the patient knows which specialist clinic he should go to, of course, he can go directly to clinic without the family doctor permitting. Patients in Germany are free to choose doctors. German doctors and hospitals are prohibited from advertising. Insurance companies are also barred from recommending doctors to patients. Therefore, the majority of Germans choose a clinic near their houses or work places. Once the patient's condition become serious, the family doctors or clinic doctors will help them to contact the hospital. The medical system of "clinics responsible for outpatients" and "hospitals responsible for inpatients" in Germany is undoubtedly very reasonable. It conforms to the natural law of illness, which not only facilitates the patient, but also improves the treatment efficiency.
All German hospitals have emergency departments. In addition, a certain number of "emergency centers" are distributed in urban and rural areas.The clinic doctors take turns on duty, about one or two night shifts for the "emergency center" are made every quarter. German ambulances usually reach their destination within 10 minutes.
2. colorful learning experience
2.1 Overview of Soest City Hospital
Klinikum Stadt Soest is located in North Rhine-Westphalia, Germany. North Rhine-Westphalia is located in western Germany with an area of 34,080 square kilometers and a population of over 18 million. It is the most populous state in Germany and the most economically developed region in Germany. The Soest City Hospital is a general hospital and a practice teaching hospital of the Münster Medical School. It was founded in 1908 and its history can be traced back to the 12th century. The hospital has nearly 20 clinical departments and research centers such as cardiovascular medicine, emergency medicine, and CyberKnife treatment center. It has 17,000 inpatients and 32,000 outpatients each year.
2.2 Learning in thedepartment of Cardiology
The department of Cardiology is the key specialty of the Soest City Hospital. It has more than 50 beds in the general ward, 10 beds in the intensive care unit , and some advanced ward beds. The scale is small, but great strength and reputation in the region. The department's services include diagnosis and treatment of acute and chronic coronary artery disease, heart failure, arrhythmia, pulmonary embolism and heart valve disease. Interventional catheterization of coronary angiography, PCI, and pacemakers (including CRT and ICD), Structural heart disease can also be carried out.
Professor Achim Meissner, director of the Department of Cardiology, is the editorial board member of Braunwald's Heart Disease. He is an internationally renowned expert in cardiovascular disease, and he has considerable experience in interventional treatment of coronary heart disease. Dr. Dees-Löbel who is in charge of our training is the teaching secretary of the department of cardiology. She is a savvy and versatile person with good clinical and interventional skills and proficiency in cardiovascular examinations such as echocardiography. Especially admirable is that she is a language genius who is fluent in five languages (German, French, English, Spanish, and Greek).
Professor Lins is an international expert in the field of cardiovascular intervention,and also "all-rounder". He is good at various types of cardiovascular interventions. He is one of the earliest cardiovascular experts in Germany who performed transcatheter aortic valve replacement (TAVR). Academic exchanges and surgical demonstrations have been conducted around the world, and he has visited hospitals in Beijing, Hangzhou, Qingdao, Chengdu and other cities in China for many times. He practiced at many hospitals in North Rhine-Westphalia, and regularly went to Dortmund Hospital every Friday for structural heart disease interventions such as TAVR. He is kind and humorous. I have communicated with him a lot and learned a lot of new ideas and techniques from him. What really appreciated me was that when he knew that I wanted to learn TAVR technology, he offered to take us to Dortmund Hospital 50 kilometers away to learn TAVR . He always drove to Dortmund at 6:45 am and took us home after the operation. In the past three months, I have studied nearly 20 TAVR cases with him, each of which was successful without complications.
What impresses me most is the normative and collaborative spirit of treatment here. TAVR patients are basically 80 years old or older, and require general anesthesia. The risk of surgery is very high, and the cooperation of doctors from different departments is required. I still remember a 90-year-old TAVR patient. The anesthesiologist first intubated under general anesthesia and performed TEE guidance at the same time. The cardiologist and the cardiothoracic surgeon worked together to implant an artificial aortic valve for the patient. The cooperation throughout the operation was very smooth and completed in about 1.5 hours. Watching the procedure was just like enjoying a symphony.
The follow-up of the patients was also done very detailed. For example, the patients post PCI were routinely reviewed every three months (Once the condition changes, they will pay attention to it at any time). What's more important is that all the data are completely recorded and saved. Therefore, perfoming a high-quality clinical research was also aconvenient here. Even simple central venipuncture was routinely performed under ultrasound guidance, which guarantees the standardization and safety of the procedure.
The doctors and nurses always paid great attention to each detail. All surgical scrubs and towels were disposable with good texture.they were not only waterproof, but also had good breathability. The equipments in the cath lab were also well maintained, clean and methodical. After using the machine, the nurse always carefully wiped the DSA pedals and cables. These details could reflect their work attitude.
The doctors and nurses in the catheterization room were friendly and enthusiastic, and they often took the initiative to introduce the informations about the patient and procedure to me. Even if they noticed that I was very interested in something, I hadn't asked them, they would introduce to me actively . Many nurses spoke English very well, so we could keep communication almost without barrier.
I also visited the echocardiography room . there were more than 10 echocardiographic examinations averaged every day. Generally, TEE was performed first, then TTE, and stress tests were also performed. During the examination, the doctor would ask the medical history and explain the result to the patient in detail.In general, the doctor and patient experience would be good when working in this way.
2.3 The experience of daily life
1) Convenient transportation.
Germany's railway and highway network provides convenient transportation services for travel. The good habit of "cars yield to pedestrians" reflects the civilization of the entire society. Most bus stations have electronic screen displaying the time of bus arrives, which is convenient for passengers to check. You can also use Google Maps for public transport related queries.
2) Beautiful environment.
Soest is a town with a medieval heart coupled with a vivacious spirit and body. The environment here is pleasant with magnificent and fascinating landscape.The air here is fresh. Under blue skies and white clouds, there are green hills and fields everywhere. Green beautiful moss can be seen on the stones of rampart and on the trees . Although the apartment is four kilometers away from the hospital, we would like to walk to the hospital as long as it does not rain.
3) Comfortable life.
Although our apartment is relatively far from the hospital, there are two supermarkets nearby (KAUFLAND and REWE). All the necessities in the supermarket are readily available The quality of the goods is excellent and the price is not very expensive.
4) Healthy diet.
We had breakfast, usually a bread and a cup of coffee, at a nearby bakery . The hospital provides lunch, mostly rice, pasta, steak, pork chops, ham, fish steak, french fries and other foods, plus vegetable salad and desserts, which is generally adaptable to us.
In general, the experience of studying abroad has widened my horizon, gained experience, and made some friends. I understand the differences between Chinese and German healthcare systems. How to integrate the advanced medical technology and humanistic care concepts into my daily work is the goal that I need to continue to make great efforts after returning to China.
