I would like to extend my heartfelt thanks to Juin and Helen from Gloryen for their invitations, as well as to Director YANG and Head Nurse Mrs. Chen from the Guangdong Provincial Hospital of CM for organizing this lecture.

At 5:30 yesterday morning, I rushed to the airport, barely able to keep my eyes open by the time I boarded the plane. When I woke up, I had already arrived at my destination. The moment I stepped off the plane, I immediately felt the heat of Guangzhou. I took off my jacket, grabbed a quick meal, and headed straight to Prof. Mueller’s lecture.

Prof. Mueller discussed various techniques for reverse shoulder arthroplasty, and what impressed me most was the pre-op planning part. Using virtual reality and navigation technology to pinpoint the center of the glenoid provides excellent precision. Such techniques is taking the medical industry by storm, powerfully driving its progress. However, performing surgery on patients with glenoid or humeral head deformities still presents certain challenges.

During the case presentation, the meticulousness of the German doctors became evident. This excellence isn’t just empty talk—they truly follow each step methodically and according to the protocols. From pre-op planning to intra-op contingency plans, post-op rehabilitation, and follow-up, German doctors like Prof. Mueller work in a well-organized and orderly manner.

Germany has its own bone and tendon banks in hospitals, which makes the options of allo-bone or allo-tendon grafts quite convenient. Cadavers and femoral heads are important sources for these banks, and this is legal in Germany. German doctors have been using the LARS ligament 20 years ago, but such artificial ligment is now rarely employed. One reason is the cost, and another is that the German surgeons believe artificial tendons cannot grow in with bone. Even though short-term results appear satisfactory, there is a risk of loosening and failure in the long term. German doctors place the highest importance on long-term outcomes.

In patients with combined ACL and MCL tears, Prof. Mueller prioritizes ACL reconstruction and later monitors the healing of the MCL after conservative treatments. In most cases, the MCL heals (80-90%) with a brace being applied for 4 weeks. However, it should not be fixed all the time during this period; patients should perform flexing exercises at 30 degrees, extend, then flex to 60 degrees, extend again, and finally flex to 90 degrees before extending. This is to prevent stiffness and joint adhesion. If the ruptured MCL does not heal, the method used by Prof. Mueller involves placing anchors at the torn ends. After suturing the tendon, he would pull the pigtail to the uninjured side and secured with a Pushlock. This aims to enhance the strength of the MCL. To prevent heterotopic ossification after MCL reconstruction, Prof. Mueller recommends taking oral non-steroidal anti-inflammatory drugs (NSAIDs) for 2 weeks, while most doctors in China prefer using indomethacin for about 3 weeks.

Patients undergoing knee arthroplasty do not use a tourniquet. It found that even in normal individuals, applying a tourniquet to the thigh for one hour can lead to knee pain, discomfort, and an increased risk of thrombosis. Hemostasis is achieved by German surgeons in such case using a combination of tranexamic acid infusion and local anesthesia. General anesthesia is employed for the surgery, and patients are encouraged to get out of bed 4 hours postoperatively, reflecting a rapid rehabilitation concept that is applied to every patient. After surgery, it is essential not to place a pillow under the knee for the patient’s comfort; instead, the pillow should be placed under the feet to allow for some degree of hyperextension of the knee.

In patients undergoing joint replacement, if there are symptoms of urinary low-grade infection and elevated nitrite levels, Prof. Mueller believes that this is not a significant issue in male patients. However, for female patients, he recommends drinking tea made in his own hospital. This viewpoint has been endorsed by Director Yang and Head Nurse Chen from the Guangdong Provincial Hospital of CM, who have also observed similar outcomes in their clinical practice. However, the reasons for this effect have not been investigated further. Nonetheless, this method could be explored in future clinical work to determine whether this viewpoint holds true.  

In patients with frozen shoulder, Prof. Mueller seldom performs shoulder joint release under anesthesia. The perspective is that most of these patients have underlying osteoporosis, making manual release prone to fractures. He tends to favor conservative treatments, such as oral medications combined with intra-articular injections. If these methods prove ineffective, he resorts to arthroscopic surgery. This case illustrates the level of caution exercised by German doctors, who prioritize safety above all. They avoid manual release, fearing it may lead to bone fractures, and instead opt for arthroscopic release, which poses lower risks. While I admire their meticulous approach, I disagree with outright abandoning this treatment option. Although there is a risk of fractures, if we perform manual release gently, consistently, and with care—avoiding fierce techniques—most outcomes are satisfactory. The likelihood of fractures exists, but it is relatively low. Additionally, preoperative bone density assessments can be conducted, and in cases of severe osteoporosis, it is reasonable to forgo manual release. This represents the most rigorous, scientific, and standard treatment approach.

The greatest taboo in academic communication is the cult of personality, blindly following others, and accepting everything others say without being of an independent mind. Doctors who fail to think critically will ultimately be eliminated! They cannot keep pace with the demands of the times and may mislead both the country and its people.

Lastly, we discussed German healthcare insurance system. Each treatment option has a specific budget; some patients may spend more, while others spend less, ultimately balancing out to ensure that the fund is generally sufficient. However, in Germany, taxes are quite high, requiring individuals to pay up to 50% of their wages. However, in Germany, the maximum tax rate is very high and you need to hand over 45% of your income. For example, if you earn 260,000, you need to hand over almost 110,000 to the state.

As the lecture was coming to an end, I asked a side question: how to become an excellent doctor. Prof. Mueller replied: first and foremost, you need to be diligent and continuously learn; this is the most fundamental requirement. It is also the core quality of a physician. You should read extensively and learn from the methods of others. Additionally, conducting experiments—whether clinical or basic—will help you make decisions and provide a reliable basis for independent thinking. Lastly, it's essential to maintain a good doctor-patient relationship. You should see patients before surgery; you can't just go in for the operation without having seen them the day before and leave right after. It's crucial to check on patients, especially on the day of surgery. Follow-up is also important to assess outcomes. This creates a feedback mechanism that enhances your understanding of the conditions you treat.

Prof. Mueller's words echoed in my mind, lingering...

After the lecture, Juin kindly arranged for her cousin to take me to the airport, and I sincerely thanked her for her warmth.

In the car, I received another lesson that I will always remember. The conversation went as follows:

"Doctor Zhao, what department are you in?"

"I'm in Orthopedics, specifically Sports Medicine."

"That's a good specialty! Most of the patients come in being carried and walk out on their own. Orthopedic doctors must feel quite accomplished."

"You know quite a bit! What's your area of expertise?"

"I've been working with hospitals for 30 years, and I know them inside out. I used to be in hospital information systems, but I sold the company and left that field. Let me tell you, Dr. Zhao, people still have great respect for the medical profession. If you keep at it, you'll have a bright future. Coming here to study is the smartest decision—education is the best investment!"

"Education is the best investment? What makes you say that?"

"Look at me—I only graduated from elementary school. While I don't worry about food or money now, I’ve seen that those around me who went to university ended up no worse off than I am, and they didn’t have to endure as much hardship. My biggest investment was spending 750,000 yuan on a four-day business course in the U.S."

"750,000 yuan? For four days? That's insanely expensive! You’ve got to share what you learned—it's like I’m making 750,000 yuan today just by listening, and don't worry, I’m not in business, so I’m not competing with you. Feel free to speak openly."

"As for what I learned, it’s hard to explain clearly right now, but one thing is that the course leader took us to the U.S., letting us experience firsthand what a developed country is really like. It gave me a mental framework, a model of the world, and it was very eye-opening. Another thing that stood out was the professor's first slide, which was just a question mark—nothing else. He taught us to think critically, to always ask, 'Why are we doing this?' and 'What’s the purpose?' They even took us to see an aircraft carrier. Just imagine—it sits in the water for ten years without needing a new coat of paint. The quality must be extraordinary."   

"That’s how your worldview, values, and philosophy of life (or quality) are built. But how can someone who’s never seen the world have a worldview? What’s in front of their eyes becomes their entire world, limiting them and preventing them from seeing beyond."

Three Key Insights on Learning:

If a person is like an airplane, then their youth is the runway. With a limited runway, you must seize every opportunity, give it your all, and learn as much as possible. Push the throttle to the max, accelerating your growth. When your speed is fast enough and your lift strong enough, you’ll eventually soar. The saddest thing in life is when you want to speed up, want to take off, but suddenly realize the runway has ended. Despite having the potential of an airplane, you’ve spent your life crawling along the ground like a car!

Everyone has a moment of awakening, and how early or late it comes determines a person's fate.

Friday, September 27, 2024

Written on the flight from Guangzhou to Nanyang