A comparison of medical education in Germany and the United States: From applying to medical school to the beginnings of residency

Both Germany and the United States of America have a long tradition of science and medical excellence reaching back as far as the nineteenth century. The same tribute must be paid to the medical educational system in both countries. Despite significant initial similarities and cross-inspiration, the paths from enrolling in a medical university to graduating as a medical doctor in Germany and the US seem to have become much different. To fill a void in literature, the authors' objective therefore is to delineate both structures of medical education in an up-to-date review and examine their current differences and similarities. Recent medical publications, legal guidelines of governmental or official organizations, articles in media, as well as the authors' personal experiences are used as sources of this report.Tuition loans of over $200,000 are not uncommon for students in the US after graduating from medical schools, which are often private institutions. In Germany, however, the vast majority of medical universities are tax-funded and, for this reason, free of tuition. Significant differences and surprisingly multiple similarities exist between these two systems, despite one depending on government and the other on private organizations. Germany currently employs an integrated medical curriculum that typically begins right after high school and consists of a 2-year long pre-clinical segment teaching basic sciences and a 4-year clinical segment leading medical students to the practical aspects of medicine. On the other hand, the US education is a two-stage process. After successful completion of a Bachelor's degree in college, an American student goes through a 4-year medical program encompassing 2 years of basic science and 2 years of clinical training. In this review, we will address some of these similarities and major differences.Deutschland und die Vereinigten Staaten von Amerika haben beide eine lange Tradition der Naturwissenschaft und medizinischen Exzellenz, die bis weit in das neunzehnte Jahrhundert zurückreicht. Den gleichen Tribut muss man den medizinischen Ausbildungssystemen beider Länder zollen. Trotz zu Beginn bedeutsamer Ähnlichkeiten und gewisser Querinspiration scheinen sich die Wege von der Immatrikulation an einer medizinischen Fakultät bis zum Studienabschluss als Arzt in Deutschland und den USA getrennt zu haben. Um eine Lücke in der Fachliteratur zu schließen, ist das Ziel der Autoren, die beiden Strukturen der medizinischen Ausbildung mittels einer aktuellen Übersichtsschrift darzustellen und deren Unterschiede und Gemeinsamkeiten zu untersuchen. Die neusten medizinischen Publikationen, verbindliche Richtlinien von amtlichen oder offiziellen Organisationen, Artikel in der Presse, aber auch die persönlichen Erfahrungen der Autoren dienen als Quellen für diese Arbeit.Studienkredite von über$200.000 sind nicht selten für Studenten in den USA nach deren Abschluss an einer medizinischen Hochschule, die meist in privatem Eigentum ist. In Deutschland dagegen ist die große Mehrheit der Universitäten mit medizinischen Fakultäten in öffentlicher Hand, aus Steuern finanziert und deshalb frei von Studiengebühren. Signifikante Unterschiede doch auch überraschenderweise eine Reihe von Ähnlichkeiten existieren zwischen den Systemen der zwei Länder, obwohl eines von privaten Einrichtungen und das andere von staatlichen Hochschulen abhängig ist. Deutschland verwendet aktuell ein ganzheitliches medizinisches Curriculum, das klassischerweise direkt nach dem Abitur beginnt und aus zwei Jahren vorklinischer und vier Jahren klinischer Ausbildung besteht, wobei letzteres die Studenten an die praktischen Aspekte der Medizin heranführen soll. Auf der anderen Seite herrscht in den USA ein zweistufiger Ausbildungsprozess. Nach erfolgreichem Erreichen eines Bachelorgrads im College führt der Weg eines amerikanischen Studenten durch ein vierjähriges Medizinstudium, welches aus zwei Jahren Grundlagenlehre und zwei Jahren klinischer Ausbildung besteht. In dieser Überblicksarbeit werden wir uns mit einigen dieser Gemeinsamkeiten und Hauptunterschiede befassen

New Observations of the Crab Nebula and Pulsar

We present a phase-resolved study of the X-ray spectrum of the Crab Pulsar, using data obtained in a special mode with the Chandra X-ray Observatory. The superb angular resolution easily enables discerning the Pulsar from the surrounding nebulosity, even at pulse minimum. We find that the Pulsar's X-ray spectral index varies sinusoidally with phase---except over the same phase range for which rather abrupt changes in optical polarization magnitude and position angle have been reported. In addition, we use the X-ray data to constrain the surface temperature for various neutron-star equations of state and atmospheres. Finally, we present new data on dynamical variations of structure within the Nebula

Chandra Phase-Resolved X-ray Spectroscopy of the Crab Pulsar II

We present a new study of the X-ray spectral properties of the Crab Pulsar. The superb angular resolution of the Chandra X-ray Observatory enables distinguishing the pulsar from the surrounding nebulosity. Analysis of the spectrum as a function of pulse phase allows the least-biased measure of interstellar X-ray extinction due primarily to photoelectric absorption and secondarily to scattering by dust grains in the direction of the Crab Nebula. We modify previous findings that the line-of-sight to the Crab is under-abundant in oxygen and provide measurements with improved accuracy and less bias. Using the abundances and cross sections from Wilms, Allen & McCray (2000) we find [O/H] = $(5.28 \pm 0.28)\times10^{-4}$ ($4.9 \times10^{-4}$ is solar abundance). We also measure for the first time the impact of scattering of flux out of the image by interstellar grains. We find $\tau_{\rm scat} = 0.147 \pm 0.043$. Analysis of the spectrum as a function of pulse phase also measures the X-ray spectral index even at pulse minimum --- albeit with increasing statistical uncertainty. The spectral variations are, by and large, consistent with a sinusoidal variation. The only significant variation from the sinusoid occurs over the same phase range as some rather abrupt behavior in the optical polarization magnitude and position angle. We compare these spectral variations to those observed in Gamma-rays and conclude that our measurements are both a challenge and a guide to future modeling and will thus eventually help us understand pair cascade processes in pulsar magnetospheres. The data were also used to set new, and less biased, upper limits to the surface temperature of the neutron star for different models of the neutron star atmosphere.Comment: 32 pages, 6 figures submitted to the Astrophysical journa

Optimizing Exposure for the Occipital Nerve in Migraine Surgery while Maintaining Hair Length

Summary:. Surgical decompression of the greater occipital nerve is used in the treatment of migraine headaches. Generally, hair is removed from the posterior scalp to aid with exposure and minimize interference. The securing of occipital hair with surgical tape and rubber bands instead of preoperative hair removal is a viable alternative. The preservation of hair length can lead to better patient satisfaction by avoiding the hair length discrepancies and has demonstrated a low risk of surgical-site infection

Age-Related Differences for Male-to-Female Transgender Patients Undergoing Gender-Affirming Surgery

Introduction: It has been theorized that there are 2 subgroups within the male-to-female (MtF) transgender population: individuals who are predominantly androphilic and those who are predominantly gynephylic or interested in both male and female partners. Aim: To explore the role of a dichotomous distribution of age at dysphoria onset in individuals diagnosed with MtF gender dysphoria. Methods: 40 patients who presented to a surgical clinic in Germany for gender-affirming surgery (GAS) were included in this study. Their age distribution was plotted as a histogram and the population was then divided at the median self-reported age of onset of gender dysphoria—that is, those 17 years and younger and those 18 years and older. The 2 groups were then compared with regard to demographic data, partnership history, various quality of life parameters, as well as sexual orientation and sexual history. Main Outcome Measure: Self-designed questionnaires for demographics and sexuality, Questions on Life Satisfaction and Body Image (FLZM), Freiburg Personality Inventory, Rosenberg Self-Esteem Scale, and Patient Health Questionnaire were used. Results: Early-onset, gender-dysphoric MtF patients underwent GAS at a much younger age (mean 32.7 vs 43.8 years, P = .004), but had similar characteristics regarding weight, height, body mass index, marital status, and living situation to individuals who reported later onset of gender dysphoria. Preoperatively, they showed greater depressive symptoms (4.6 vs 3.3 points, P = .045), which disappeared after GAS. Following surgery, the younger MtFs were predominantly attracted to men (52.6%), whereas individuals who were diagnosed with late-onset of gender dysphoria preferred women or both men and women (85.7%) as sexual partners (P = .010). Younger trans individuals were more frequently sexually active (73.7% vs 42.9%, P = .049). Conclusion: Our findings suggest that there are 2 MtF populations that differ in age of dysphoria onset, sexual history, and multiple personal details including sexual orientation. These data may be used to improve care to transgender individuals by providing treatment reflecting their sexual interests.Zavlin D, Wassersug RJ, Chegireddy V, et al. Age-Related Differences for Male-to-Female Transgender Patients Undergoing Gender-Affirming Surgery. Sex Med 2019;7:86–93. Key Words: Transgender, Male-to-Female, Gender-Affirming Surgery, Sexuality, Age, Quality of Lif

Safety of open ventral hernia repair in high-risk patients with metabolic syndrome: a multi-institutional analysis of 39,118 cases

© 2018 American Society for Bariatric Surgery Background: Metabolic syndrome (MetS) entails the simultaneous presence of a constellation of dangerous risk factors including obesity, diabetes, hypertension, and dyslipidemia. The prevalence of MetS in Western society continues to rise and implies an elevated risk for surgical complications and/or poor surgical outcomes within the affected population. Objective: To assess the risks and outcomes of multi-morbid patients with MetS undergoing open ventral hernia repair. Setting: Multi-institutional case-control study in the United States. Methods: The American College of Surgeons National Surgical Quality Improvement Program database was sampled for patients undergoing initial open ventral hernia repair from 2012 through 2014 and then stratified into 2 cohorts based on the presence or absence of MetS. Statistical analyses were performed to evaluate preoperative co-morbidities, intraoperative details, and postoperative morbidity and mortality to identify risk factors for adverse outcomes. Results: Mean age (61.0 versus 56.0 yr, P\u3c.001), body mass index (39.2 versus 31.1, P\u3c.001), and prevalence of co-morbidities of multiple organ systems were significantly higher (P\u3c.001) in the MetS cohort compared to control. Patients with MetS received higher American Society of Anesthesiologists classifications (81.0% versus 43.1% class 3 or higher, P\u3c.001), were more likely to require operation as emergency cases (11.4% versus 7.2%, P\u3c.001), required longer operative times (103 versus 87 min, P\u3c.001), had longer hospitalizations (3.5 versus 2.4 d, P\u3c.001), and had more contaminated wounds (15.9% versus 12.0% class 2 or higher, P\u3c.001). Overall, they had more medical (7.5% versus 4.2%, P\u3c.001), and surgical complications (9.7% versus 5.4%, P\u3c.001), experienced more readmissions (8.3% versus 5.7%, P\u3c.001) and reoperations (3.4% versus 2.5%, P\u3c.001), and were at higher risk for eventual death (.8% versus.5%, P=.008). Conclusions: The presence of MetS is related to a multitude of unfavorable outcomes and increased mortality after open ventral hernia repair compared with a non-MetS control group. MetS is a useful marker for high operative risk in a population that is generally prone to obesity and its associated diseases