EPISODE FIFTEEN｜The World’s Great Doctors with Prof. Ulrich Stöckle

For EPISODE 15 of the World’s Great Doctors, it is our great honor to have Prof. Ulrich Stöckle as our distinguished guest, who is the Managing Director of the Center for Musculoskeletal Surgery of Charité - Universitätsmedizin Berlin and the President of AO Trauma Germany.

Charité is undoubtedly the TOP 1 hospital in Europe, according to multiple international rankings. And the Center for Musculoskeletal Surgery of it led by Prof. Stöckle has been ranked among the TOP 3 orthopedics-specialized hospitals by the U.S. Newsweek for consecutive 2 years.

In Germany, Trauma Surgery and Orthopedics used to be two independent fields before 2004. As early as 2003, the team at Charité had been keenly aware of the overlap of the daily work of the two fields and the potential synergy resulting from merger. They then get started reforming and later established the first Center for Musculoskeletal Surgery in Germany.

Prof. Stöckle talks to Gloryren about how he manages such a large center, including the challenges and future plans as well as how he and his team train the young generation. As the President of AO Trauma Germany, he calls for active engagement in international exchanges to further develop the field and the individual clinical expertise of the colleagues.

Please check the recording of the interview below

1. Why did you decide to pursue a career in medicine and why, in particular, did you decide to specialize in trauma surgery?

I was raised in a family of a lot of doctors. My father had his own practice for internal medicine. My grandfather and two uncles were surgeons.So I became pretty familiar with the topic of medicine and especially how to help people.And (as for) trauma surgery, after my medical studies, (I realized that) it was very impressive because one really can help people in the way that they come in with broken legs and they walk out on their own legs again after adequate treatment. This way, you see the results of your work, more or less, immediately. With a clinical result, X-rays, and so on, you have a precise control of what you're doing. This was really very fascinating, I remember just one case, in the US actually, a young patient with a femoral fracture getting in on the stretcher, and about five days after, he walked out on his own legs again. This was very impressive and made me just decide really to go to trauma surgery and to pursue this way.

2. Who have been your greatest influences? What have they taught you and how have they inspired you?

The greatest influences, first, were the family and the doctors within the family, to see what they are doing and to see how fascinating this is. And then, later on, there have been teachers. Actually, my first teacher was Jürgen Radke in orthopedics, and then Norbert Haas for trauma surgery who I had a chance and pleasure to learn a lot during the 14 years from 1992 to 2006 in Berlin at the Charité already, and having the chance to build up really one of the most important trauma departments within Germany and actually Europe. Norbert Haas was really a great influence and of course with the other coworkers like Norbert Südkamp and Reinhard Hoffmann. These are the main influences during the last years.

3. In 2007, you received a call from the Technical University of Munich, your alma mater, to be the Chair of Trauma Surgery there. And four years later, you took over the position of the Medical Director at BGU Tübingen, which is one of the top trauma centers in Germany even worldwide. Why did you choose to come back to Charité after you had held these two top positions?

That's a very good question because especially as the BG Trauma Hospital Tübingen is a very big hospital specializing in trauma. As you said it is one of the most important and well-known centers within Germany and maybe even Europe or worldwide. It developed, being the chair before, for more than fifteen years. But about four years ago, it was the decision either to stay in Tübingen or to decide to do something else again. At the same time, there was a lack here at the Charité. They needed a new chair for my former department, a new chair for trauma because after Norbert Haas, Michael Schütz came to Berlin and after two years he left again for Australia. So the position was vacant. The thinking was there are not that many to be able to take over this position, especially in this situation, and with all my still-existing network within Berlin, knowing a lot of people and especially knowing most of the other trauma chairs in Berlin. We had some talks and some negotiations on if this would be an option to go there. Finally, I decided to play a role here because there is a very big potential to further develop our Center for Musculoskeletal Surgery and, of course, Charité has the ambition to be Number One on an international base. To help to go on this way is another challenge for the next years. So this is why I finally decided to return to Berlin and help my former department for further development together with the friends, Carsten Perka and Georg Duda. The main option is to further develop the center as a team with Carsten Perka and Georg Duda and to really establish the international position.

4. As the Managing Director at the Center for Musculoskeletal Surgery of Charité, what’s your plan on this position for the following years?

The initial plan as taking over this position was to, on first step, stabilize the department because it was kind of troubling a bit because of lacking a chair for about two years. This has become rather difficult within the Corona situation in the past two to three years. But now the situation is that we have a very stable development with good numbers. You all know that within the hospital all that counts are numbers, meaning not only patient numbers but that you can show that your department is economically on the good side or the safe side. This was the main part. We achieved this already.

The further plan is to develop this department together with the orthopedics part as one center and to further establish a national and international standing clinically and scientifically. So for us, it's very important to have a good research center, just like the Julius Wolff Institute led by Georg Duda, and to further improve the scientific standing and international visibility. We are able to do this with special research projects about bone healing, different aspects of joint replacement, and developing new implants with different companies. I'm really looking forward to motivating young doctors to get engaged in these different projects and really to be on top of innovation. This is also why we now have an intraoperative CT, work with navigation, in terms of technology, the integration of 3D printing etc. The plan is to have our Center for Musculoskeletal Surgery as a leading department within Germany and Europe-wise or internationally, which has been, more or less, already achieved, looking at the Newsweek Ranking for two years in a row and so on. On the other hand, that's the only way to motivate young doctors when you have a clear goal and to go to with always having the patient at the center of your thinking and treatment. So the main goal is the high-quality treatment of patients. To show this not only to the patients, but externally as well, and to establish a more and more profound scientific standing internationally. That's about the goal.

But we know nowadays the main part of our work is how we can get good co-workers and how we can keep them on track. This is taking more and more time. Especially the younger generation is very active, but they want to know what they are active for. It's a lot of communication but it's not only necessary but also an exciting part of the work - we can still motivate young doctors to go this way and to be part of the development of being a well-known and visible department nationally and internationally.

5. Currently, more and more university hospitals in Germany are merging their orthopedics and trauma surgery into one klinik or center. Charité has founded the Center for Musculoskeletal Surgery in 2003, in which all sub-specialties run independently with close collaboration and two Chairs are retained. Is it the first of its kind in Germany? And what inspired or motivated Charité to do so? After the development of the last two decades, what advantages do you see from this structure?

In 2003 actually we were first ones to design this center for musculoskeletal surgery. There were different reasons. First, we saw the international development - this is why the name is already international. Second, and there was a clear development within Germany, that the two fields of trauma surgery and orthopedics are getting closer together with even forming one, so called “facharzt” - a doctor’s degree for orthopedics and trauma. To explain this a bit more, in history, trauma surgery was pretty close to surgery and all of us, before becoming trauma surgeons, we have to become surgeons. So general surgeons and then put trauma surgery on top, whereas orthopedics was an independent special fields. I think around 2004 or 2005, this system of common doctor for orthopedics and trauma was established within Germany, meaning that there was no need for trauma surgeon to become a general surgeon before, but the way is to become the “doctor for orthopedics and trauma” and then you can specialize to specialized trauma surgery or specialized orthopedics surgery. With this, it was clear that we have a common feel because of lots of overlaps within our daily work, meaning trauma surgeons do a lot of joint placements for femoral neck fractures and for distal femur fractures and so on, and that experts in joint replacement in orthopedics deal with periprosthetic fractures. We do have a lot of overlap, and each field can benefit from the expertise of the other field. Just like periprosthetic fractures, for the orthopedics, how to do a plate osteosynthesis or how to do an osteosynthesis, and for the trauma surgeon, how to do a perfect joint replacement.

So these developments made us to think about establishing a common center, to have some synergies and have the opportunity to offer to our residents an overview and an option for a complete learning within both fields to become a doctor for orthopedics and traumatology.

In the years after, there were other university institutions starting with the same idea, just like Regensburg, Freiburg, and just recently Munich. The next advantage is that, once you are one big center, you are even bigger within your hospital institution, meaning, even at the Charité, we stand for at least 10% of the overall surgeries, of the overall income, of the overall scientific output and so on. So this increases your importance and once you come up with some research applications, this, again, increases your power and your visibility.

6. According to multiple international rankings, Charité is undoubtedly the top 1 hospital in Germany and in Europe. There are 75 surgeons in your center, who complete 8500 operations per year. What’s the biggest challenge to manage such a large center at the best hospital?

There are several challenges. One major challenge is that we do have the center at two different campus. We have one campus here at the so-called Campus Virchow with the trauma especially being the focus and we have the other campus in the center of Berlin - Campus Charité Mitte with more reconstructive part being the focus. For our co-workers, this means sometimes getting from one campus to the other. On the other hand, this means we cannot offer our specialties at every campus, but we have a differentiation as I said already - more reconstructive on one campus and more trauma, tumor, etc. on the other campus.

What may challenge these days, is, as I said already, to get the best co-workers and the best residents and to keep them and to find a good way to motivate our young doctors to stay and not only to stay until they get their degree for orthopedics and trauma but to stay further on to become attending and to get more experience clinically and work in a research field. This is the main challenge and this is why we need special career pathways, for example, the clinician-scientist. We have different pathways, starting as a junior clinician-scientist, the young doctors can apply and 20% of their salary is funded to enable them to be at least one day per week within the research project. This continues later with the clinician-scientist funding of 50%, which enables them to spend 50% of their working time with research in parallel to the clinical path. Most of the time, this means they go for three months into research and then three months again into the clinical path, having a career path clinically and scientifically. This is a very important element for the career planning of our young co-workers and this is why we need very close communication, especially with the young generations, as I said already. They need to know what for they are working here. They need to know what gonna happen in two years, three years, five years... They need a clear career plan and this is what we try to establish, in some of them successfully, but some of them still to be improved. This is our main work and not only I am doing this, as I pointed out again, together with Carsten Perka and Georg Duda, offering clinical and research opportunities. This is very important and this is the only way to stay ahead, stay active and stay motivated to keep this position. You said Charité is number one in Germany and Europe, yes and this has been even improved during the last years of the importance within corona treatment and so on. As a reference center, we, on the other hand, need to stay in the surgical field, and trauma and orthopedics at this level, and this needs a lot of effort, but the main thing is really to motivate our residents and to show a clear career plan.

7. As a professor, a surgeon, the director of a center, how do you balance your personal life, administration, clinical practice, research activities and lecturing?

Being in this position as director of the center and still being a surgeon means you need a tight schedule and you need a very good surrounding. We do have a clinical manager to organize things a bit. And you have a tight schedule for OR time, for outpatient time and clear appointments for administration. For example, Monday afternoons are mainly for administration or faculty meetings, and I try to have at least half a day for my administration activities. For Tuesday afternoons we have research meetings. The clinical work is mainly in the time between eight and one or two o'clock, while in the afternoon there are more administration meetings and research meetings.You try to have it on a regular base that you have certain days within the week, just like mentioned, Monday, Tuesday, to stick to this agenda and really be able to do this because everything needs to be in the right order. The administration wants to have good numbers of your clinical activities. And, of course, you have to be clinically active and to see that everything is on the right path to assure high quality. Besides that, you must have enough time for research activities, which mainly means to give good ideas for different research studies and for lecturing. So, it's a lot of coordination necessary, but finally it works out. Sometimes it's a long day, but there's a way.

8. Do you have suggestions on how to train the young generation? What advice would you give to the young trauma surgeons?

Thank you, very difficult questions.

The suggestion for the chairs is really to talk with the young doctors and try to form a plan for the following three to four years, so they really have their rotation plan in advance and they know what's going to happen in two years. This is very important, besides the career pathways as pointed out before, like the clinician-scientist program.

For the young generation, it's important to show them as early as possible that, as a medical student, the best fascination of trauma surgery, as I said before, is to be able to get the injured patients back onto their own feet and to include within the training, some hands-on training like hands-on training on artificial bone models and so on, and to keep this motivation.

Suggestion for the young generation is that they can ask for clear career pathways - what am I about to get once I start here and things like that. In terms of career, it's good to get some international experience or to go abroad for some time to see different structures, different cultures. Especially in trauma surgery, I think the German-speaking areas, Germany, Austria, Switzerland, are very well known, as well as Northern America. Getting some experience there may be very beneficial, especially for the career itself. 

And try to start some research projects. To be visible. As the publisher of two German journals as well, we've noticed already that we get quite a lot of Chinese papers even for a German-speaking journal. So there is very high activity. And I think it is very fascinating that once you start this clinical career parallel to a research career and you get motivation by itself, you will see that you would have very good options later on to find a fascinating job opportunity.

9. You have been the Chair of AO Trauma Germany since 2019. What does this mean to you? How important do you think the professional societies like AO Trauma, EFORT are to the field of orthopedics and trauma surgery and to the surgeons?

AO Trauma is the most important worldwide network of trauma surgeons, being established about 60 years ago. So it's a great honor to chair this for the German chapter, which is the second biggest worldwide with more than 800 members and around 50 educational events per year. I think it's very important to get engaged, already as a young surgeon, within this network. This is why we say we grew up within this institution - in the beginning, you go to one of the courses or to Davos, you meet a lot of international friends and you can establish international connections and international friendships and benefit from it because you can discuss cases and can increase clinical experience this way. So it's very important.

And, once you work in the field like Trauma Surgery, or Orthopedics or whatsoever and you're ambitious, I think it's important to try to be part of the movement and to be able to maybe change something or improve something. This is why it's important to engage in the scientific societies like our German Society for Orthopedics and Trauma Surgery, and then even international societies. EFORT is the biggest European society for trauma and orthopedics, its aim is to increase the quality of care in Europe and to establish a common standard. It is, on my point of view, very important and to be part of this movement is exciting and a great honor. Once you have the chance, you should be part of it and should take it. 

These different societies are important and they just need from the engagement of the different members. I think it's good to be part of it and I can just advise to everybody to try to engage within this. Within EFORT, we already have quite a lot of abstract applications from China actually, because obviously it's a bit easier to travel to Europe than to the US, which is good. Trauma and orthopedics is one of the biggest fields within medicine, since there are lots of disorders within the musculoskeletal system, not only trauma, but also orthopedics. So we need to show this and to improve the overall situation, especially the quality of care. It's important that we engage ourselves wherever possible, and this is why I really recommend this to everybody to do this. 

10. What’s the trend of trauma surgery in the coming decade?

In the coming decades, trauma surgery will be influenced, like all other fields within medicine, by digitalization and technology integration. So we need a clear pathway of the patient data to assess. And we now already have technology integration with intraoperative imaging, being CT quality, we don't have the need for post-op CT anymore, instead, we got intra-op MRI, intra-op navigation, and image fusion, which is existing already that you can fuse X-rays, CTs, or MRI and whatever available and then maybe you will have glasses that you can see the operation CTs but also someone else sitting somewhere can assess the operation CTs. To have this technology integration and to have patient data from getting into the emergency room to the OR. Having them available, you can work on them wherever you need them. Besides that, within technology integration, robotics will be a certain part. Within our work, we already have the first results of robotic treatment of pelvic and acetabular fractures, and the same for the spine. We will have more technology integration to increase precision and assure high-quality good results. These would mainly influence our work in a positive way.

On the other hand, we need to have enough co-workers and enough residents, this is why we talked about different career and personal pathways, and to keep our co-workers motivated. But I think it's very fascinating, especially with this technology integration, it will even be more fascinating.

11. You enjoy a great international reputation. What is your proudest career achievement to date and why?

It's hard to tell but probably the proudest one is being Chair of AO Trauma Germany. As I pointed out already, AO Trauma is the most important network and society within trauma surgery worldwide. To represent the German chapter, which is the second biggest, really is a great honor.

12. The COVID-19 pandemic is one of the biggest challenges facing modern healthcare. What impact do you see this having on the field of orthopedics and trauma surgery?

The Covid pandemic has a great influence on our daily life, especially on the life and work within the hospitals. Even nowadays, we have, on a daily basis, coworkers being positive and patients being positive and not able to be operated. And we do have different studies show that the numbers of trauma stay more or less the same during the different pandemic waves, except for the first wave when we really had a shutdown here of the public life when even trauma went down, but in the other waves, it was kind of the same. Whereas orthopedics really has decreasing numbers because elective surgeries were the first ones to cut down.

Our main problem nowadays is that there is, kind of, a “new normal”, even so far we could not get back to the situation like in 2019 because there are not enough OR personnel and personnel on the ward. There is fatigue within all these different working groups. And we are still missing an adequate number of employees within OR nursing and nursing on the ward. This is why, in several hospitals, the OR capacity is still down to 70% or 80%, and even if we are at about 90%, but not anymore 100% compared to 2019. This is one of the main problems, especially what we see additionally is that smaller hospitals transfer more patients because they cannot take care of some of the complex trauma cases anymore due to missing personnel. This has been the main problem right now. We'll see how we can manage this in the future, but with all this experience, there will be a new normal that this will not be 100% from 2019 because Covid is still accompanying us and we have to see what's going to happen in the autumn. It's will be very challenging.

13. What’s the most fascinating part of your profession as a medical doctor? And what would you have been if you had not been a medical doctor?

The most fascinating part is the diversity of the different activities. First of all, it is treating patients and being able, in most of the times, to help patients to get back to their formal mobility and activity. This is really the most fascinating part. But besides, you have the research, you have the lecturing part, teaching young students... Teaching young and active people is very fascinating as well. Besides, chairing this department or center, is just like leading a small company. So it's really the diversity of the different activities that is the most fascinating thing. The center of the work is, of course, the patient treatment and the other part, is to have the patient really trust in you and you are responsible to get the the injured patient back to his or her activity before the injury. So that's the main fascinating part.

And in fact, what if not a medical doctor or if not a trauma surgeon? I probably would have studied economics because numbers are fascinating as well as economics, and you could do your own business and have a combination of economics digitalization and new technologies. This would have been probably fascinating as well, but not as fascinating as the profession as a medical doctor.

14. What are your hobbies during your leisure time?

Within my free time, I try to enjoy life and do some sports just like running, skiing in winter, and being on the water, just like sailing, in summer. And to travel a bit to enjoy good places and to get some recreation.