On Sept 17, the Third Sino-Euro Global Forum on Hospital Management, Specialty Construction and Talent Cultivation reached a perfect conclusion in Xiamen, China. Eight key academic leaders from Europe, 300 Hospital Presidents, key academic leaders in different specialties, heads of administrative departments and outstanding young doctors from nearly 50 Grade III-A hospitals in 18 Chinese cities attended the forum in person. The promo-article published on Gloryren’s WeChat account attracted more than 63,000 views. The live broadcast attracted more than 200,000 clicks.

For the forum, we selected National Grade III-A hospitals, Grade III-A hospitals from first-tier cities, Grade III-A hospitals from second-tier cities, specialized hospitals and private hospitals. We present the current situation of Chinese hospitals from various levels of portraits. Fifteen questions were discussed on the forum by the Sino-Euro hospital presidents for best possible solutions. Only talents make a hospital great. Doctors reflect the conscience of a country. To a well-reputed Grade III-A hospital in China, what you need is a real academic leader instead of a head of a department. You are located at the prime location of the first-tier cities. It is the greatest support from the country that makes your achievement today. It is not because that the President is great. The real greatness lies in the greatness of the team. We used to be one of the most underdeveloped countries worldwide. It took us nearly 40 years to make China the second largest economy worldwide. The three-year-long pandemic empowered China global standing of its healthcare system. The pandemic promoted the importance of healthcare to an unprecedented level. After all, the healthcare system represents the international image of a country. The most important criteria of healthcare are healthy population, well-being index, disease control system and material reserve. The priority of a Chinese hospital should be hospital management, specialty construction and talent cultivation. Being a hospital president is not an ordinary job. Every hospital president in China should help develop and support primary hospitals. This is what you’re here for. Only with social stability, people's happiness and physical health, can a country truly become strong and prosperous.

Hospital Management

Moderating Chairs: Prof. Stief, Prof. SHEN Jie, Prof. LIU Jihong

Panel Members: Prof. WU Song, Prof. Siebert

1. What is the core of a hospital?

Prof. Stief: The question is how to deal with the obvious problems and tensions between the administration and the individual department. I think it's very obvious that we do have problems, we do have fights. And at least in my experience, it is most important that we have an open and transparent discussion between the head of the administration and the head of the department. We should openly and honestly talk about the aim of the hospital, the aim of the department, and the perspectives.

What is our purpose? What is extremely important is that we openly talk about our limited budgets. I don't know how specific the situation in China is, but at least this situation in Germany, this situation in Munich is always that we don't have enough money for all the things we would like to do, like to buy and like to perform. So I think open discussion is very important. 

Tell the people this is our budget, there are our aims, and how we will get there. And then what I think is extremely important is to leave these specific questions and how to solve these problems within the department, but not try to leave the peripheral problems for central administration. The core of the hospital, I think is the patient. And the patient is the utmost focus for us. And just to treat the diseases of patients, we need lots of things. We need obviously human resources. We need the interaction of human resources. We obviously need a building to live and to work in. And then we need things that we put into the building, equipment. We need the technician that monitors the equipment. We need the nursing staffs and the doctors, and then take care of the doctors.

Prof. LIU Jihong: I think we have the same situation here for general hospitals. Large hospitals in China also do budget management. At the end of each year, we do the budgeting. And our government also emphasizes the allocation of budgets. Second, the most important thing for a hospital should be core talents. Doctors are important core talents, so are the staffs in administrative departments, the nurses, and the senior management teams. So overall, core talents are the core to maintain the competitiveness of a hospital. But in everything we do, we must focus on serving patients and relieve their sufferings by improving our medical level and service quality.

Prof. WU Song: Another important factor in China is the position of a hospital given by the government. If a hospital is a primary hospital, it should focus its services on the patients in the community. If it is a high-level hospital or a regional medical center, it may be serving patients of a province or a certain region. As an administrator of a public hospital, we are more like the chairman of a state-owned enterprise. Our task is to follow the guideline and position set by the government, to make good use of our speciality or strength, and then accordingly to hire talents, procure equipment, and make plans.

Prof. SHEN Jie: What is the core of a hospital? I think it involves the core values, core talents and the core development strategy of a hospital. After going though the COVID-19 pandemic, we should think about what we should do in this post Covid-19 era. I think the specialty development is the core of a hospital and the momentum for the future development. We know that during the “14th Five-Year Plan” period, China has the “Hundred-Thousand-Ten Thousand Project”. It means that we will build one hundred national key specialties, one thousand provincial key specialties, and ten thousand county-level key specialties. We are now learning from West China Hospital of Sichuan University and Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology. But not every hospital could turn out to be these two hospitals. Therefore, each hospital should figure out its own position. During the development towards this position, specialty development is very important and is the core and drive. At the same time the core of speciality development is talents.

Prof. Siebert: Let me just point out one thing. As the number of patients that we treat continues to grow, we also have to be aware of the fact that we have to make the processes for the physicians, for our doctors as efficient as possible. Should it be the support by artificial intelligence in form of digitalization of the hospitals? Should it be a form of staff members that support your doctor? In Germany, we have learned painfully, I have to admit, that we need to improve the efficiencies of our processes so we get as much treatment per dollar as we can, if you have a limited budget. So you have to make sure that you have your doctors doing the things that they should be doing to help your patients and keep them from having to do too much administration, from having to do other things, because we need their talent to be focused on the patients. 

2. How to coordinate the relationship between the clinical departments and administrative departments as a President of a hospital?

Prof. Stief: The relationship between them should be respectful from both sides. I think the administration should respect the doctors who try to get the best for patients. Doctors should respect that the administrator has a limited budget, must finance the entire hospital and must balance all the needs that the different departments have. So there should be an open discussion. There should be clear messages from both sides. And in the end, there should be a respectful compromise.

Ms. PENG: I think among Chinese hospitals, very few of them have well-functioning administrative departments. I know a spine surgeon from a hospital in Guangzhou who is very self-motivated and working very hard. Not long ago, he received an invitation for fellowship from Sch?n Klinik München Harlaching and also got his visa. However, the administrative department refused to give the doctor’s leave request because they said that it was none of their business. If any problem occurs during the fellowship which is approved by the administrative department, they have to take the responsibility. But the German hosting hospital had already arranged everything well for this doctor I think this hospital has an irresponsible administrative department. I've visited many hospitals. Every time I visit a hospital, I tell the president that the administrative department is supposed to support the clinical department. Why? Because outpatient services are provided by doctors, and surgeries are also performed by doctors. However, doctors often have to beg for approval from the administrative departments. Later, the doctor gave me a phone call, saying that he wanted to quit from the hospital. Actually the president of the hospital tried to support him, but failed. This is not an uncommon situation in Chinese hospitals. And that’s one of the reasons why we are holding this forum - to improve the situation of the medical industry of China.

Prof. Siebert: In Germany, the situation has developed a little bit. Whereas 10 years ago, I would say there was a battle between the administration and the physician. We have learned that we need to address common goals to make sure that our hospitals continue to function. Right now, if you will, the enemy for us is new legislation, and changes in the rules. We have to keep the hospital on its toes, if you will, to adjust to the new setting. So the game needs to be played together to be successful. And I think many of our administrators have learned that they can only run a successful hospital that if they have their doctors on board and that they form a proper team.

Prof. LIU Jihong: The case that Madam PENG mentioned was a quite exceptional one. At the early stage, there were indeed some limitations on studying abroad, but now the situation has been improved a lot. I still remember one saying from our former president that, “Our hospital should serve the patients wholeheartedly. Patients come first”. Since clinical doctors are the ones who serve patients, medical science departments serve the clinical doctors on the front line, and all the administrative departments serve the clinical and medical science departments. Administrators’ work is to serve every staff, so they first have to overcome the “official-centered” thoughts. They are not officials but servers with administrative function. Administrative departments ought to know the difficulties and challenges that doctors are facing, as well as keep every medical staff aware of national policies and administrative regulations to improve the quality of their medical services. Administrators and clinical doctors should show mutual respects and understandings, because they are working for a common goal - serving for patients and relieving their sufferings.

Prof. WU Song: I fully agree with the idea that administrative departments should serve the medical departments. But what kind of criteria should we use to assess the outcome? In Chinese hospitals, we use satisfaction surveys that have two parts. One is the satisfaction level of the patients, including outpatients and inpatients, to see if they are satisfied with the services, diagnoses and treatments provided by our staffs. The other is the satisfaction level of our employees. Our hospital and health commissions of all levels do the satisfaction surveys for administrators, medical staffs, and others respectively. So as an administrator, we can introduce corresponding incentive measures according to the outcomes of the satisfaction surveys.

In our hospital, I propose that we should build a warm hospital and we should deliver our warmness to our patients. Also, for our employees, including medical staffs and administrative staffs, we must work out some specific incentive measures to show our warmness. If the satisfaction level is quite low, we have to introduce some corresponding measures to improve. Eventually we can create a hospital where people feel warm.

Prof. SHEN Jie: Administration and medical care require a management system of the presidency and department-level. We should not emphasize one thing at the cost of the other. This is my point.

The second, in recent years, while we are stressing specialty development and talent cultivation, we might have ignored the training of administrative staffs. But in recent years, we have seen a lot of good signs that all kinds of training courses of hospital management were organized by our government, which is good for the improvement of the management ability of administrative staffs. We have witnessed the improvement.

The third is that administrative staffs must serve the clinical departments. They have to be clear with their duty. A hospital should serve the doctors because the core of a hospital are good doctors and they must be supported by administrative departments. So a good hospital must have a good administration team.

Meanwhile, a satisfaction survey is very important. To be aware of problems in time and solve them are also important. I remember a paper saying that the number of administrative staffs should be less than 10% of all employees and the number of professional practitioners should be more than 60%. People have different thoughts on this idea. Clinical staffs might think that the income they earn are given to support the administrative staffs. But, administrative staffs also often work very hard and overtime. So my point is that administrative staffs must know that their purpose is to serve the clinical departments. With this attitude, they can help to build a good hospital. Ten years ago, when I was a candidate for the president, my leader had a talk with me. One of his words that made me impressed is that, “We entrust you with this important task. But this doesn’t mean that you become a superior official, but only means that you bear more responsibility to serve the hospital better. And this is the only way to a bright future.”

Prof. Siebert: In Germany, with the development of the diagnostic related groups, for the last 20 years, we have been fighting against financial limitations, which has led to the doctors and the administrators, when they were sitting down talking about budgets, to have completely forgotten about the nursing staff on the wards and the operating rooms. This has led to these jobs to have become very unattractive, at least in Germany. So right now, we in Germany have many qualified doctors, but we do not have enough nursing staff. So I would encourage China not to make the same mistake. For a doctor to function properly, and to treat as many patients as possible, he needs to have the proper amount of staff. So do not reduce the support staff just to keep your doctors happy. 

The problem for the administrator will always be to keep everything in balance, for example, the low budget, the number of patients you have to see in your region, and of course the staff that you have available. So this becomes very difficult. In Germany, there is no training for chief surgeons, if you will, during their medical school time or during their residency, how to become a good administrator. We, in Germany, have to do extracurricular activity to learn these things. I think it should become part of the curriculum for the hospital doctors so that they are introduced to these columns early and do not have to start learning on the job.

3. Doctors, nurses, and administrative departments are all pursuing the well-beings of the patients. But sometimes patients complain that they do not receive sufficient respect and emotional care when being treated in large hospitals and feel anonymous. How to promote patient satisfaction without increasing workload of the clinical staff?

Prof. Stief: I think that's a problem for all over the world, not only for Grade III-A hospitals. We must be aware. When you have a big health problem, you have to go to the hospital, have to leave your family, your friends, and go to a foreign place, so you're pretty much alone. You're desperate because you don't know what's gonna happen and how you will get out of that hospital. So you're pretty lonely in the end. And I think we have to develop strategies to help these people in their lonely situation.

We, as the Department of Urology, have decided that a very small group of doctors take care of 7 to 10 or 12 patients. We request the doctor who takes care of a specific patient to be present in the surgery that the patient will get. So he sees the patient not only when the patient comes to the hospital, but also follows what is happening to that patient, and how is he operated. 

self as the chairperson, all our staff members, and all our residents can be reached by email anytime. So just to give you an example, I'm here in China now for two days. I have replied at least 40 emails to our patients. They’re not long letters, but mostly it's just words or sentences to help them. So we really try to be available for our patients all the time, even when they have left the hospital or when they may develop problems afterwards.

Prof. LIU Jihong: How to provide the best services to our patients is an everlasting question of hospital development. In China, we fully agree that the concept is to serve the patients with heart and soul. With this idea, we use various methods, such as optimizing processes, to provide better services. I often ask our administrative staffs to go to the “front line” to act as patients and to experience the medical treatment process, so that they know where the problems are, and know how to reduce the steps and simplify the process.

Right now, I think the most important thing is to develop science and technology to optimize the process, such as auto registration, online booking and auto payment. The development of these IT and AI technologies can largely reduce our labor input cost.

Another thing is to enhance the development of e-hospital and tiered medical services. Some patients with simple diseases can be treated in smaller hospitals. And medical resources should be given to patients who are really in need. We understand that patients trust Grade III-A hospitals and they prefer to come to Grade III-A hospitals. And every patient is equal in terms of their rights to receive medical services. Therefore, we need to guide them in a correct way. We can use brochures, posters, telephones and WeChat to serve our patients and reduce the processes. In general, we should use all kinds of methods, including administrative, medical, technological ones, etc. to optimize the process and improve the quality of our services.

Prof. Siebert: The major problem is that the patient is in an unfamiliar setting in the hospital. He's in an unhappy place. So we have to do what we can to make him comfortable, to make him familiar with this setting. I have found, much as has been said already earlier, that I like to have the same nursing team, the same physical therapist, the same doctor to see the patient as often as possible so that he becomes comfortable in his setting, which, of course, requires the senior staff members to be delegated into smaller groups so that the patients have a common denominator of their treatment. We try to create a unit which treats the patient from day 1 to the final day to make him feel as comfortable as possible.

Prof. SHEN Jie: This question shows that Grade III-A hospitals indeed attract a lot of patients. The first thing we should do is to optimize the medical treatment process. Nowadays, hospitals are larger and larger with more and more employees. Back in the old days, hospitals were small and one employee could manage to link all the departments. But now cooperation among all the departments is needed to finish all the processes.

Second, we should make good use of the customer service center and public opinion monitoring system. I know that Singapore does very well with their feedback system and it’s the best part among their services. Every time we go to an airport in Singapore, the staffs will ask for our feedback on their work. So it is very important for the customer service center to find problems in time.

Third, the support from IT is also essential. Once we transfer common patients to lower-level hospitals according to our tiered medical system, we can have more time and resources to develop and optimize our specialties.

Another thing I find crucial is to build a warm hospital. I remember one hospital administrator once said that, to be patient-oriented is a must for a hospital, and it’s equally important to be employee-oriented. Because when the employees are happy, patients will enjoy better services; when the employees feel secure, so do the patients. Therefore, we need to improve the satisfaction of our employees while paying attention to patients’ satisfaction.

4. Apart from the satisfaction of patients, the quality of medical care is also a significant standard to assess the quality of a hospital. To improve the quality of medical care, one is to improve the treatment outcome, second is to monitor and avoid risks. How to achieve these two goals from the perspective of hospital executives?

Prof. Stief: This is a very important point, the quality of medical care. In most major indications like myocardial infarction, stroke and surgical procedures, we do have national databases. For us in a surgical department, I do have access to a national database so I can look up how long a pancreatic resection could be, how high the blood transfusion rate could be, what major complications could be, like pulmonary embolism. And as the Board of the hospital, we do carefully look into these numbers. And all our chairpersons have at least one official talk to the Board every year. And if it is a structure department or is it cardiology where we have these huge databases, we take the numbers before, share the numbers with the chairperson, and then we talk about the results. If the results are satisfactory or even better, we are more than happy. If the results are sub-optimal, we talk openly with that chairperson. Why do we have a problem in such specific surgeries? Why is your outcome not good? So we warn him. If next year, the results are not significantly improved, there would be an immediate sanction. So we really try very hard to improve our medical treatment results in all different areas of medicine.

Prof. WU Song: To maintain the quality and safety of medical care is a very important task for every administrator of hospitals. How to improve the quality to the highest and reduce the risk to the lowest? Every administrative department of our hospital should have a series of specific measures, which we are quite familiar with, to achieve these goals . As a well-established hospital, management is relatively easier. However, for a brand new hospital, establishing a system to monitor the quality of medical care and reduce risks could be quite challenging, because the personnel’s familiarity and compliance to the regulations might be different, and we have to see if the processes are reasonable and practical, and if the supporting equipment are enough to cover all the medical services. Therefore, it is more challenging.

According to the performance evaluation index system of tertiary public hospitals in China, the proportion of administrative staffs should be less than 10%. I think this idea is only half correct as we have to control the labor cost. However, for the sake of the quality and safety of medical care, to have enough administrative staffs is very necessary. Therefore, we need to introduce or train high-level administrative talents. In all processes of medical care, we must take this into account. Also, with advanced IT system, we can collect data for us to truly improve the quality and safety of medical care in both new and old hospitals.

Prof. LIU Jihong: the quality and safety of medical care is an everlasting topic for our hospitals. And our national government is also paying close attention to it. Recently, I watched the Second China Medical Quality Conference where 18 Core Regulations of Chinese Medical Quality are enhanced to improve medical safety, including medical record writing, ward rounds, checking, and safety management of surgeries, etc. When I was the Director of the Department of Medical Affairs, I asked all the departments to check each other’s seven records for discussion, including the records of death cases which we could learn lessons. These are the basic job. So for a hospital, the first thing to do is to improve the treatment outcome and reduce the death rate. The second is to ensure safety. For example, we should pay attention to drug complications, unnecessary falls and injuries, and iatrogenic injuries, etc. Therefore, we should establish a basic system of our hospital and build up the concept of the quality and safety of medical care. And I think this is the same for all the hospitals in the world.

Prof. Siebert: I, of course, agree wholeheartedly. But you do not always have to invent the wheel again. There is enough literature out there as far as the benchmarks that your department should be able to reach. At least in Europe, there are many very different certification processes that have analyzed the problems in hospital structures in the past. And you just need to employ this to your setting to have a stable environment. You need to find balance in how much time you have your physician spent on quality control, because you always have to remember that this is the time they will not be able to spend with their patients. So in Germany we will use the benchmarks that are out there and compare our results accordingly. We have a Hygiene Department that keeps monitoring our infections, our bacteria in the hospital for us. And they present the data on a regular basis. So we need the support of administration and various sub-specialties to help us surgeons get the best results. And we have found it helpful to have a critical incident reporting system to see problems as they arise and try to solve them before the patient is actually harmed.

Prof. SHEN Jie: the quality and safety of medical care is a constant topic in hospitals, and is the lifeline of a hospital. I think the 18 Core Regulations of Chinese Medical Quality are established based on the past painful failures. Therefore, in the assessment of Grade III-A hospitals, the management system of the presidency and department-level, especially PDCA, is very important. We should “apply a Grade III-A hospital standard to the daily work”. When we are in a daily routine of work and there is no superior inspection, we might ignore some problems. But I think it is necessary for a department to analyze its medical quality on a daily basis, because with the development of specialities, a lot of critically ill patients with refractory diseases need the regular examination.

Second, we should stick to the 10 Inpatient Safety Goals, which is very important, including the safety of surgeries, blood transfusion, the formation and prevention of venous thrombosis, etc. Hospitals should check these aspects regularly.

Third, we notice recently that as a three-year action plan for improving surgical safety and quality from the National Health Commission will be started soon, the performance appraisal of public hospitals emphasize the development of surgical departments, surgical skills and safety problems. With the promotion of performance appraisal of public hospitals in China, every hospital “encourages physicians to perform small surgeries, encourages surgeons to focus on minimally invasive surgeries, and encourages MIS surgeons to focus on precise treatment”, etc.

Ms. PENG: A classic saying goes, “it doesn't matter how high you fly; it matters if you can land safely”. Hospitals have a complicated system where doctors and nurses have to work very carefully. So for every hospital, the most important thing is to control risks. Only if you control the risks to the least in your hospital, can the quality of medical care of the hospital be guaranteed.

5. Most of the hospital presidents are clinical doctors. How to become a professional hospital administrator? How to reach new heights based on the achievements of predecessors of the well-organized hospitals?

Prof. Stief: I think you’ll learn the job during your work. You start as a medical student, then continue as a resident, then a staff member. You learn more and more to cope with administrative things, to cope with serious incidents, to cope with risks and the results. And then as you become the chairperson of a clinical department or a surgical department, you're dealing and talking every day with the administration. You're dealing with budgets. And if you then become the medical director or the vice director of a hospital, and possibly a huge hospital, this is just another scale, but the mechanism behind it is absolutely the same. So at least my personal conception or experience is that when you are a clinical doctor, you’ll run through the hierarchies over the years. Then you’ll get pretty much experience to run a hospital.

Prof. WU Song: Actually I think everyone has different experiences. When I was a surgeon, if I did the same surgery for 100 or 200 times, I would be confident with my skill to do this surgery and I could tell the patient proudly that I could successfully perform the surgery. But scientific researches and translational researches are sometimes much harder than doing surgeries, because you will face a lot of uncertainty while doing scientific research, and you have to explore scientific gaps, but actually there is not so many gaps for you to explore.

When it comes to management, it is even more difficult. Maybe many of you here feel it easy, but, for me, I think it’s harder than doing surgeries and scientific researches, because management involves all the departments, vice presidents, superior departments, and the whole industry. We also have to deal with budget, look for resources and make the plan that all of the staffs could follow. We now have a President Responsibility System under the leadership of the Party Committee, which could support the presidents.

For these three aspects as well as the quality and safety of medical care as mentioned above, it takes one life time for us to keep them balanced and choose one over the other. There might not be an optimal choice, but in my opinion, if we can serve more patients, create more opportunities for people, and develop more platforms for our nation and regions, it would be a great relief to see these.

Prof. LIU Jihong: This is a common topic for all of us here. On the way of becoming a President of a hospital from a clinical doctor, I have been performing surgeries, providing outpatient services, doing scientific researches and teaching for many years. Tongji Hospital is a large hospital with more than 8,000 beds and more than 10,000 employees. So from my point of view, it’s relatively easy to be a surgeon but it’s difficult to be a good president.

First of all, being a president have to be 100 percent concentrated. After I became a president, I don’t do outpatient services or perform surgeries because there is too little time and our hospital is too large. Another experience of mine is that at a certain stage the development of a hospital or a department can be very fast. As long as correct methods are used, departments can develop rapidly, and many indicators will show large improvements. The Tongji Hospital is like an aircraft carrier with three campuses, more than 8,000 beds, more than 10,000 employees, including 9,600 of them at work and 1,400 retired. Also, our hospital is now in a high position in all kinds of ranking. However, I think it is still very hard to make true breakthroughs, keep pace with top hospitals of our nation, and be a nation-class and world-class hospital.

We need lots of methods and philosophies, but absolutely not those ordinary methods that we’re using now. We need to make a huge leap, but at the same time we have to work on details. Currently, we have been learning from many hospitals in China, including such aspects as canceling drug price addition and consumables addition, DRG payment, and the budget of medical insurance. So hospital administrators are facing more and more complicated problems. How to satisfy our patients and streamline the service procedures while at the same time satisfying our employees and making them feel that they are respected? This is a very demanding job for presidents. And I think the only way is to do delicacy management.

It’s hard to find a breakthrough at this stage of development, so for a hospital, instead of ordinary management, delicacy management on all aspects is necessary, such as talents, scientific research, teaching, information technology, operation, administration and hospital culture. This is the most likely way to improve the hospitals to a higher level at an bottleneck stage, especially for large hospitals, like us. I think that only if we learn from the world and have exchanges with each other, can the hospital management be better.

Prof. Siebert: Let me just add that we expect our leaders in the medical department that they take advantage of the talent pool that they have. They need to find the talents, the researchers; they need to find the surgeons; and yes, they need to find the future managers of hospitals in their group, and then support them accordingly. And my point earlier was that you don't automatically achieve competence in hospital management by being named as Chief. I believe we send surgeons to courses for the AO to learn how to deal with trauma, and send them to research groups. But what we seldom do is to send the budding future chiefs out to management courses. But we should support these people just as we do for our researchers and our surgeons so that they are ready to face budget discussions and administrative problems which they may have seen but they have never had to address directly. So I think there's a lot of talent out there. And we just have to make sure we draw as much potential out of our groups as possible. And for that we need to take advantage of international sources and exchange programs. But this has become very difficult to do with the staff shortages, in Germany, at least, to convince our administrators that this is an important tool to further our departments.

Prof. SHEN Jie: Specialty development is quite important. The development of clinical work is focucing on specialization and that of administrative work is on extension. So administrators growing from clinical doctors have their advantages. Also, turning clinical doctors into administrators can expand the view in management. They have several advantages in management. One is in the construction of specialty. As they are familiar with the specialty, they can do better to integrate specialties, make plans for groups of specialties, and can have a better understanding of the concept of “a sub-specialty department should be able to treat some diseases that show its characteristic, a specialty department should be able to treat some diseases that show its advantage and a hospital should be able to treat some diseases that show its strategy, and even of the future development of hospitals.

The second is how to make good use of their professions to develop with innovation and differentiation. The integration of all kinds of new technologies, such as in medicine and engineering, needs a broader professional view and sensitivity to integrate all the ideas on specialty development. President XI Jinping has said that “innovation is a key for development and a key for the future”. Therefore, whether in science, technology or all sorts of integration, specialty development would bring progress to administration.

Third, for specialty construction, some directors of departments are good doctors, but not necessarily good administrators. So we have assessment programs of sub-specialties or specialties to help them analyze and guide them to be excellent administrators.

Speciality Construction

Moderating Chairs: Prof. Hildebrand, Prof. LI Xu, Prof. LI Xugui

Panel Members: Prof. Mueller, Prof. Stinus

1. How to collect, induce, analyze, and sort out the clinical data and to select appropriate topic/cases for clinical research? How to balance the resources put into clinical care and into research? 

Prof. Hildebrand: Thanks very much. I think Prof. Stief already mentioned the importance of national databases. And also in orthopedics and trauma, we have quite a lot of databases for the different injuries and illnesses. We have a database for severely injured patients, for geriatric patients, for pelvic trauma patients, for spine trauma patients, and so on. And I think it's very important to analyze data from all these databases so that you can see how is the quality within your hospital is, because you can compare it with other hospitals from all over Germany and you also can use the data to look where the need for clinical research is. For example, for severely injured patients, our database is 25 years old and we have several hundreds of thousands of patients. We can see how the treatment develops and which measures really help to improve the outcome of the patient. I think this is really helpful to define the new topic for clinical research. How to balance the resources is a difficult question, because the clinical care of the patient is always number one. Then you have to deal how to find resources for research, so there might be third party funding. Often there are programs from the university for research for young residents, so you have to find some resources to do research but what is really important, and, I think, is really needed is that you have a full time research service in your department. Otherwise it will be hard to have a clear program and structure of your research.

Prof. Mueller: Sometimes I have a new idea for study. And at the beginning, I need some data. If I start a prospective study, it needs a lot of time to get some results. Therefore I go to the patient charts to look for the data to make a retrospective study, because it is quicker to get a result. And then I look in the charts and I see I'm missing a lot of information for the patient. Therefore, I think it's very important from the beginning for every patient to have good data, and then work together with other clinics, share your information, and then you get first results. Then you see if your study idea has the chance to get a innovation, a new information for our population. Then you can start a prospective study and to validate your idea. I think we need big data. We must have good systems to put in the information and make it available for all of us.

I have a little bit of different opinion of Prof. Hildebrand. I think we need specialist researcher, but also our clinical doctors must make research, because they see the patients, they see the diseases and they can have new ideas. We must work together and at the moment in many of our university hospitals, the experimental research is done only by engineers, by biochemistry researchers, but not by the doctors. Sometimes we have a research the medical doctors can't understand, so we must be more close to the clinics to work together with these specialists and then we get better resource.

Prof. LI Xu: I want to share my thoughts from my own experience. I worked as a director of a department in a public hospital for 8 years, and now I have been a director as well as a president of a private hospital for about 5 years. From my 13-year experience in developing specialties, I think it’s very important to collect effective, valuable, and true data for specialty construction and researches.

I had profound experience when I worked in a public hospital. In public hospitals in China, especially Grade III-A hospitals, due to the busy clinical work, it’s hard to collect the correct and detailed data when we record the information of patients although we have a strong medical information system to help us. For example, we ask the colleagues of Information Department to help us collect all the cases of a disease and provide us with the patient list. However, when I look at the medical records, I find many information that I need missing, and some of them not accurate but recorded based on assumptions. And this makes it difficult for me to do a retrospective or conclusive research. 

For instance, last year, we submitted a paper about a refined surgical method developed by us to GCS. We used some detailed information of cases with follow-up of more than five years. Among all the information, I needed a specific one - the blood loss for each surgery. However, when I checked cases of five years ago, I found some of their records missing, and some of them very rough. As surgeons, we all know clearly that after a surgery, if the data are not accurately recorded, we just guess the blood loss is 500 ml or 300 ml, but we know these are inaccurate.

Therefore, when I started to work in the current hospital, I require all the colleagues in the OR to record very specifically the amount of saline used to clean the wound, like using injectors of 50 or 60 ml. Also, the blood should be sucked into the suction canister because we can measure the amount. If we use gauze to wipe the blood, we must weigh the gauze after the surgery. In this way, the error of blood loss record can be controlled within 10 ml at most. And these accurate data will be an important reference for clinical researches of the surgical procedure.

Second, another example, the data of range of motion of the joint is also not accurate in many of the medical records. If we want to assess the clinical outcome of a treatment, we need a lot of scoring and grading systems which are often from English literature or textbooks and are very detailed. The medical records in many public hospitals were written by fellows and postgraduates. And the senior doctors might be too busy with clinical work to check the records, so many of the records and patient’s information were recorded inaccurately, and sometimes were even incorrect. That is to say, among our thousands of clinical cases, to select the correct and useful information is very difficult for many hospitals and their clinical doctors.

Therefore, in my department and my team, we have secretaries to specially take care of this. Each of our chief physician works with a clinical assistant, enabling the chief physicians to do the most important parts and to get rid of the paper work. And clinical assistants will help them to check patients’ conditions, such as gait and range of motion of joints. We have photographers to record every child’s gait, their walking video, range of motion of joints, etc. to leave data as accurate and detailed as possible, which is helpful for the clinical research in the future.

Prof. LI Xugui: I also agree with the idea to build databases. In our clinical work, we receive a lot of patients. Every patient, and every information relevant to a disease can be a database. Why are we doing researches and how should we link databases with researches? The purpose of clinical research is to better treat diseases or to explore a more effective and better treatment. For every disease, we must first build a database. After having a good database, then we can do data analysis and summary. Then, we compare different methods with statistical approaches to choose or find a better treatment.

2. The style, bedside manner and ability vary from surgeon to surgeon. How to provide patients with homogeneously high-quality operation and care?

Prof. Hildebrand: It is of the utmost importance to have guidelines and standard operation procedures for every injury and every illness you treat, so that every doctor can rely on special recommendations and knows how you want to do it. Secondly, I think it's very important that you have regular rounds within your department. In the morning, we see all patients who come at night, look at the X rays. And the residents tell us how the clinical findings are, so you know what happened there. And in the afternoon, we have rounds where we discuss all operations for the next day. And the surgeons will tell us what he plans to do, which implants he wants to use, which approach he will use, and we discuss it. And if I don't like the idea, you have to change it. And I think that's important. And you have to see your patients on the wards regularly, so you have to have a look at the soft tissues. You have to have a look about mobilization and so on. And that's the responsibility of the director of a clinic or of the attending to have really good look at the patients.

Prof. LI Xu: We have a morning rounds, afternoon rounds and discussions to make sure every patient is receiving the medical care of the same quality and high standard. As for the question of doctors’ styles, I’d like to talk about this.

I worked in the Pediatric Orthopedics Department for more than 10 years. And we treat patients from 0-18 years old since people under 18 years old are children according to WHO. The difference in both physical and mental conditions of these patients is very large.

We have five young surgeon in our team. Some of them are amiable, while some are cool. Young kids like those friendly doctors, while the teenage girls like those cool doctors more. Our doctors have different styles.

Back to the problem of medical quality control. I very agree with the two German professors that we must have a set of strict standard to control the quality and guarantee high quality in the outcome of each patient, each treatment, and each surgery.

For example, in the OR, we place a blackboard of about one square meter beside the X-ray film viewers, and I require all the surgeons to write in Chinese and English the range of motion of each joints on three planes and six directions, as well as the length of limbs, the flexibility of rotation, flexion and extension to keep the surgical quality consistent during the surgery.

In brief conclusion, we have to take every doctor’s personality, educational background, style and cultural difference into account. However, we still need a set of agreed and strict standard to follow for medical care.

Prof. LI Xugui: To achieve the homogenization of surgery and medical care, we must follow the agreed clinical standards, like the clinical pathway. And the process of diagnosis and treatment must be standardized. We allow different styles of doctors as this is normal. But the first and foremost, we must follow the same standard. In this course, we have to train ourselves and learn to reach the standard. Each individual, of course, has different personality, since we have different cultural and educational background. It doesn't matter. What matters is that we must follow the agreed standard when treating patients.

3. How to realize multidisciplinary cooperation for the prevention, conservative treatment, surgical treatment, perioperative rehabilitation and home-based rehabilitation of orthopedic diseases?

Prof. Hildebrand: For example, if you are treating a severely injured patient and he's coming to the trauma bay in your emergency department, the trauma team who is there needs to be predefined. You have to talk to your other departments and you have to clarify which doctor is needed at what time. And you have to do it before the patient arrives, but not when the patient arrives. You have to be prepared in your hospital. For example, when treating geriatric patients, you have to talk to your colleagues from internal medicine, to treat all the internal illnesses and then the fractures. And that has to be predefined before the patients arrive. The same is true for the cooperation among hospitals. In Germany, we have, for example, a so-called trauma network. It combines hospitals within a region to organize the trauma management of patients. If a severely injured patient arrives at a smaller hospital after the accident, he will be transferred to a larger one. And this is already organized, so the larger hospital cannot say “I don't have time”, I don't have a bed”, or something. He has to take it. And that makes it easier for all of us. In this setting, pre-hospital management and rehabilitation after the treatment are also included. And I think the same is true for all the other severe injuries. You have to have this cooperation to provide the best treatment for patients.

Prof. Mueller: Patients come with a disease to us. Sometimes they have not only orthopedic diseases, but also some other critical illnesses. Therefore, we must cooperate with other disciplines. In Germany, in orthopedics, for a long time, we have done lots of conservative and surgical treatments, as well as rehabilitation. At the moment, in our Musculoskeletal Center of University of Munich, we have specialized trauma surgeons, orthopedic surgeons. And we also have the doctors for physical therapy and rehabilitation. We work together. That's a good way to make big efforts for patients, but we also need some other disciplines. I'm also the Chief of the Interdisciplinary Sports Center. In this center we work together also with the cardiologists and other disciplines to find the best solution for patients. That means sometimes it needs one doctor who organizes mainly the cooperation with other disciplines for the disease of the patient. We have guidelines. And we have more and more centers like Comprehensive Cancer Centers and Coma Centers. Therefore, we work together with these other disciplines. And I think that's the future, because most of our diseases of our patients is not only a topic for one discipline, is also a topic for more disciplines to cooperate.

Prof. LI Xu: Take my own specialty as an example, we have treated the most patients with cerebral palsy (CP), which is more than 200 cases annually. And it is the most challenging condition among all the patients with orthopedic diseases. For these kind of patients, surgeries are only one part of the treatment. As we often say “surgery only accounts for 30% of the treatment process of CP while rehabilitation accounts for the other 70%”, CP patients even have to do rehabilitation throughout the whole life. Surgeries are just interventional treatment in between. For the comprehensive treatment for these patients, besides their surgeons, nearly doctors from all disciplines have to be involved, such as those from pediatric orthopedics, rehabilitation, pediatrics, neurosurgery, nursing, and nutrition, psychology and language support teams, etc. Therefore, the process involves a multidisciplinary cooperation in assessment and treatment.

Now, because of the advancement in screening technologies such as the rescue of newborns, we could diagnose CP in patients at a very young age. Clinically, we could find CP patients younger than one year old, but for children under 1 year old, they haven’t learned to walk, and the motor development in CP children is much worse, so it’s very hard to diagnose CP in children at such a young age. If they are not diagnosed until they reach the age of six or seven, or more than ten, they would have to undergo big interventional surgeries. Therefore, if we can identify those patients earlier, we could help them with rehabilitation as well as intervention and guidance from pediatricians, nursing teams and others to avoid the risks of surgery. They must be followed up during their entire childhood from 0 to 16 or 18 years old. We should keep doing rehabilitation therapy and multidisciplinary interventions at all times, including home rehabilitation and online guidance.

Prof. LI Xugui: During the entire process of diagnosis and treatment of orthopedic diseases, that is ‘before, during and after patients’ hospital stay, our hospital has implemented an approach of “integration of medical treatment, nursing and rehabilitation”. In our hospital, rehabilitation has been combined together with all the orthopedic specialties and inpatient wards. Rehabilitation therapists are sent to different inpatient wards based on the features of diagnosis and treatment of each ward, and are actively engaged in the treatment through this close cooperation approach. During this process, we also introduce the concept of enhanced recovery after surgery (ERAS), and explore to combine ERAS with Chinese characteristics and integrate with western and traditional Chinese medicine. For the follow-ups of patients, we have a special team to take care of that. With follow-ups, we collect the data of treatment outcomes and patients’ satisfaction towards every aspect, and use the data to improve the quality of our diagnosis and treatment. 

4. For patients with sports injuries, do you set up an independent sub-specialty of sports medicine or the patients are referred to anatomically-oriented sub-specialties?

Prof. Hildebrand: I think every orthopedics clinic in Germany is subdivided into different anatomical sections. And I think this is also of most importance to have really the best care for the patients for their specific situations. If a young person who has a fracture in his ankle is going to sports or to the foot section, the treatment should be done by the best available surgeon. It might be a foot surgeon or sports surgeon. It depends probably on the departments. However, we also need generalists, especially in trauma surgery. Imagine there is a severely injured patient coming to your hospital and he has a fracture in his femur, but the attending physician is a specialist in shoulder, and said, “oh, I'm sorry. I'm a specialist in shoulder surgery. I don't know how to take care of your femur.”

In my department, every resident and every attending has to be some kind of a generalist to know how to act in the most important emergencies. You can be specialized, but you also need to know how to treat acutely injured patients, otherwise we will have big problems, especially at night when specialists are not in the hospital.

Prof. Mueller: I think if an athlete comes to an hospital with an injury, he needs the best treatment by a specialist. And if he comes with an ankle joint injury, he needs a treatment from the foot and ankle joint specialist, but there are also specific aspects for an athlete concerning doping, the drugs, treatment to get back soon to competitions. For example, if I treat a patient with a cartilage defect, I can do something like micro-fracture or autologous chondrocyte implantation, but that means he can't do sports for about half a year or one year. If I have an elite sportsman and it’s not possible to say that “you must stop your sports for half a year”, then I need another treatment like cartilage bone transfer or something. Therefore, if I'm the leader of a Sports Medicine Department, I must have specialists, and I must discuss with them what are the special points for an athlete, for the treatment, and also for the recovery rehabilitation. That means we must work together, for example, in a tumor surgery, the tumor surgeon resects the tumor. And afterwards, the shoulder surgeon performs the reconstruction. That's also important for sports medicine to work together with other disciplines.

Prof. LI Xu: In different specialties, hospitals, countries, cultural backgrounds, we might not have an one-size-fits-all answer. Some Chinese surgeons in Sports Medicine Department are very good at endoscopic or microscopic surgeries for knee, hip or shoulders, but ankle injuries may go beyond their specialties and probably the patients should go to Trauma Department or Foot and Ankle Department for a better treatment. And Prof. Mueller mentioned the same thing for cartilage damaged patients. If they have to undergo a micro-fracture surgery, should they go to Trauma Department or Sports Medicine Department? These are real questions that we need to answer. Whether we should set up a sub-specialty or not, and how to optimize the arrangement of specialties, the premise is to provide the best quality of care for patients. We should have the consensus on the ultimate goal. And we should take the background of our hospitals and our treatment level and advantages into account.

One important thing I want to say is that, from my experience in both public hospitals and private hospitals, in many of our hospitals, especially those with large orthopedics departments having many specialties, a common problem is that different specialties are competing for patients. Like the example I mentioned just now, should a patient with an ankle injury go to the Sports Medicine Department, Foot and Ankle Department, or Trauma Department? In some hospitals, all these three departments along with Trauma Center can receive this patient. And often the department who comes the first will get the patient. Driven by interests and profits, a lot of hospitals have this problem. Therefore, the most important thing is to know how to evaluate the KPI of a doctor, a department, and the quality of clinical work from the management perspective, but not only evaluate the performance by profits. That is a big question that administrators need to answer.

Prof. LI Xugui: There's a saying in China that “people have their own specialties”. For sports injury, we must set up a department to treat these patients. And for different types of sports injury, based on the anatomical category, we can subdivide the patients into different sub-specialties. For instance, we should treat the sports injury of an athlete differently from that of a normal patient. I would like to specially point out that doctors need to share and communicate more. Even treating a patient of sports injury may need the collaboration of other orthopedic specialties and even non-orthopedic specialties, so we need multidisciplinary cooperation. We must work together with the common goal which is to better treat the disease and help the patients to recover faster and better

Prof. Stinus: In our work, we have to have knowledge in special issues of sports, such as psychological problems and anti-doping, so it's very important to have a very good network and I send my athlete patients to specialties. If I have a trauma patient, an athlete participating in the Paralympic Games, I have to do the diagnosis as an orthopedic and trauma surgeon. In Germany, the teams of sub-specialties are very important for patients with sports injuries.

Ms. PENG: I think orthopedics should be subdivided according to anatomical parts. For example, most of the Sports Medicine Departments in China perform arthroscopic surgeries and they think that if they can do this kind of surgeries, they are a Sports Medicine Department. However, this is wrong. We should subdivide it according to anatomical parts. For instance, if a patient has spine injuries, he have to go to the Spine Surgery Department; those with injuries in shoulders, knees and hips should be received by corresponding departments; and those with ankle injuries should go to the Foot and Ankle Department. We should not establish an independent Sports Medicine Department to treat all the patients, because no one can treat all the diseases on different body parts. And if a department only perform arthroscopic surgeries, for example, for shoulders or knees, it is not a Sports Medicine Department.

5. Is it necessary to introduce high-end equipment and technologies to Orthopedics at the moment, including surgical robot, artificial intelligence, AR imaging, 3D printers?

Prof. Hildebrand: My answer is yes. It's extremely important to have good equipment, for example, intraoperative 3D imaging navigation. I think that surgical robots will gain importance in the future. I think in some fields, robots are already used, for example, in spine surgery or in endoscopic surgeries. We talked about the relevance of big data. If you really want to handle the big data, you of course need artificial intelligence. And for 3D printing, we already use it in trauma surgeries, for example, to handle bone defects and perhaps also to print patient’s specific implant. And in the answer of to the first question, Prof. Mueller has mentioned this. I think there is no serious doubts all over Germany that you need a professional head of your scientific department. Of course, the research questions have to come from the clinicians, but you have to have a manager of your lab, because, for example, if you talk about 3D printing and so on. Research is clearly multi-professional and interdisciplinary, so you have to discuss all these aspects. And if necessary, you need an engineer to do it, but the engineer needs to know from us what he has to do or what we need. And I think that's the most important thing with all these new techniques to have a multi-professional approach to really make these things work for the patients.

Prof. Mueller: When I was a young doctor 25 years ago, there was a first type of robots in orthopedics. Some colleagues used them as a marketing instrument to increase the case of arthroplasty. And after three to five years, we saw them as a big disaster, because the robots came from the industry, came from engineers without medical orthopedics experience. They made some mistakes, but that was not the main problem. The main problem was the robots went through the soft tissue and destroyed completely the soft tissue, so then we stopped it. It was a big problem. And now we have a new hype for robots in arthroplasty. If we look at the data we have at the moment, you see no benefit, but we are at the beginning and we must have this new innovations. We must have this new techniques. And we must be critical on it. It's not a marketing tool. We must use it in the university hospitals and then we will see if there's a benefit or not, or are there also some disadvantages.

At the moment, it was expensive and we got no additional reimbursement if we used it. And if we used a robot, it costed half a million euros and we got not more money, but we need the money for the treatment of our patients. For tools, we know that they help the patients. The first step for these new techniques is to study these new techniques, to get data and to evaluate it. I like these new techniques. I use it also for myself, but I think I like to be critical and give at the end some data if they have some benefit or not.

Prof. LI Xu: In my own hospital, we don't use surgical robots or AI assisted diagnosis. However, we have a 3D printing lab. And I’d like to briefly share my view on surgical robots and AI assisted diagnosis. For both of these two new technologies, we have to select the indications carefully and strictly evaluate the standards and quality of their performance. New technologies are not necessarily safe. And no technology is always safe. Last week, when Dr. Leidinger visited our hospital, he talked about limb lengthening surgeries. In the recent 20 years in the western world, they have externally controlled internal lengthening nails, while in China, we still use external fixators for lengthening surgeries which leads a lot of complications. However, even if we use the externally controlled internal lengthening nails which seem to be very safe, there is a change of up to 30% to develop complications according to Dr. Leidinger, even after some of them are tested. How to face the new technologies? The first one is to select the indications carefully and strictly evaluate their quality in treatment. Some of Chinese hospitals might think that having a new technology means they are advanced to a higher level. I think we must be very cautious with the new techniques.

Talent Cultivation

Moderating Chairs: Prof. Boriani, Prof. LIAO Yuanpeng, Prof. LIN Haibin

Panel Members: Prof. Mueller, Dr. Stinus

1. How to offer more hands-on opportunities to young surgeons? How to manage the mistakes they make ?

Prof. Stief: Our concept is that you give responsibility as early as possible. In a surgical speciality, we put our young doctors from Day 1 in the OR. As Prof. Boriani told us, we teach them step by step means. Even if we do very complex surgery that lasts 3 hours, for at least several minutes, we can let the residents do some steps and get some practical training. We do have simulators and animal facilities, so if they like, our residents can train themselves both on animals and on simulators. As far as the errors and the problems that arise during daily work and patient care, I think the atmosphere must be very open. If an error or a catastrophe happens, this should not be hidden, but it should be talked openly. An adequate answer should be found. Not only the one who caused the problem, but also all the department can learn what was the mistake, how did the mistake happen, and how I could possibly avoid that mistake in the future.

Prof. LIAO Yuanpeng: For doctors, the hands-on ability is very important. Chinese doctors actually have a lot of chances to do surgeries because we have so many cases. And I think what we should ask is how to provide them with high-quality hands-on opportunities. Many doctors are repeating simple or low-level procedures. How to provide them with better opportunities for involvement in high-quality and high-level training is a problem that Chinese hospitals are facing. A Chinese saying goes, “the more capable you become, the higher position you will be in.”

But from another perspective, I think “the higher position you are in, the more capable you will become” also makes sense. If young doctors are not given the responsibility, they might not have the ability or opportunity to get high-level practice. This also will affect the development of a department. If the chief of a department only do high-level surgeries by himself but not delegate to young doctors, the department cannot be well developed. So to have a good system of promotion and a good plan for the department should be a good way to ensure more hands-on opportunities of high quality to young doctors.

As for errors, every doctor makes errors and we learn from errors. Hospitals must have a mechanism that can allow these errors. However, young doctors should not just leave the errors to the hospital but must learn from them. This should be supported by a good system.

Prof. LIN Haibin: We all know that surgeries are the cornerstone for surgeons to grow. It is a good way to evaluate the capability of surgeons. In clinical practice, besides undergraduate education, postgraduate and doctoral education both need a mentor system. Senior doctors should teach, train and pass down experience to young doctors. I think this is important.

Second, errors are unavoidable. But in my opinion, doctors are not allowed to make mistakes because our occupation is different from others. Some severe injuries in organs and limbs cannot be cured. Nothing can replace the injured parts. It's not like a part of a machine that you can buy a spare one to replace. It's not the case. So for me, young surgeons are not allowed to make mistakes. They are even less allowed to make the same mistake twice. If that happens, I don't think they are qualified as a surgeon, and as a doctor.

Dr. Leidinger: The core system to educate for speciality is very important. This is what we have established in Germany. There's always an opportunity to cut the surgical procedure into different steps. For example, let the assistant do the easy part, then the main surgeon comes back and do the difficult part. By that, next time, the assistant can take over more responsibility. Then a year later, he is probably able to do the entire surgical procedure of this surgery under the surveillance of the main surgeon. So I think this is a good procedure. And of course, we all should prepare our surgeons by discussing the surgical steps with the assistant in advance of the surgeries and check if he is well prepared as well. He should have read up the procedure and should be able to answer the questions: what is the next step? How do you deal with this? What implant do you choose? What is the alternative treatment? By this educational system with step-by-step surgeries and good preparation of the surgical steps before the surgery, I think this is a good way to train our young surgeons.

2. How to keep the motivation high among the team?

Prof. Stief: The question is how to keep a talent. And if you keep a talent, you work with that talent for many years and for lots of time. I think if you work closely with somebody, there are the several paramount parameters. The first one is respect. I expect respect from my coworkers. However, respect is never a one-way street. If I expect respect, I have to respect them. And I think the second paramount factor is loyalty. I expect loyalty from my people. Also, loyalty is not a one-way street, so I have to be loyal to my people. And if you establish respect and loyalty in your inner team, that's already a very good factor to keep them motivated. The third point would be to give them responsibility. You check if they can bear and fulfill the responsibility, then leave them alone and let them grow. And the fourth point that at least I or our department tells the young guys is that we expect you to become better than the current generation. So I expect every young staff member to be better than me, let’s say, in five or ten years.

Prof. LIAO Yuanpeng: How to motivate a team? Everyone may have different opinions on this question. From an administrative perspective, I think there are several points. First, trust. In order to keep your team motivated, you must trust them. And second, to give them the power. Trust solely is not enough. You should give them the power so that they will be motivated to move forward. Third, there must be measurable targets and a target-oriented approach. The target should be slightly higher than their current capacity so that they will be motivated to do better. And the fourth is to use the reward and penalty system to keep the team motivated. Lastly, as an administrator, we should select members, especially the leaders, to construct an administration team. 

Prof. Stukenborg-Colsman: I think, in every clinic, there is a natural hierarchy in these teams. But in Germany, in general, besides this natural hierarchy which has to be there, we try to flatten it a little bit in order to build up a team. I think it's important to have a team spirit in your clinic so that every member of the team feels important and knows what to do. What do we do for the motivation? In our university clinic, we have research projects. And the teams take more and more part in these research projects so they see their personal development in terms of their clinical development and also as a researcher. And I think this motivates them. My intention is, at the end, all my team members should develop themselves as individuals, clinical surgeons and researchers. 

Prof. LIN Haibin: I think that talents are the core resources for the development of hospitals as well as the primary productive force. Talent teams are a key factor in promoting specialty construction and the momentum for moving forward. And I think academic leaders play an important role in keeping the motivation of the team. Academic leaders should be broad-minded with the mentor spirit to train team members. It's very important that every member of the team is vital.

Dr. Leidinger: Apart from respect, loyalty and responsibility, the function of the head of a department, I would say, an idol, is also important. I admire my former chief doctor a lot. And I think this is also still relevant today. Probably less important, but still relevant. So the idol function means there's an enthusiasm for what you do, for the educational process, and also for the quality of medicine, and for the responsibility of the head of a department. And in addition, the team building efforts are also becoming more and more important. Beside work, you should have meetings, dinners, and parties with them, without alcohol, of course. And for the personal development for each talent, you can send them abroad, probably to a fellowship program, or an international or national educational program. I think these are the necessary steps.