Recently, patient safety has been featured in front-page headlines of major German newspapers and on news channels [1,2]. Triggered by the courageous "outing" of 17 well-established German physicians, disturbing rates of potentially preventable errors have been reported. Although the German "Aktionsbündnis Patientensicherheit" ("Action Alliance Patient Safety") was founded back in April 2005, it appears that the concept of patient safety has been "flying under the public radar" of recognition until present. Unfortunately, numerous prestigious German medical centers still consider adverse events, mistakes, and complications as a taboo, thereby preventing their own guild from learning from their mistakes and advancing patient care. In sharp contrast, the implemented standards for patient safety in the United States appear to be well ahead of the persistently anecdotal way of dealing with medical errors and complications in Germany [3,4]. Raising surgeon awareness for patient safety symbolizes medical innovation, and these advances start with medical education.

At this time, in the year 2008, there exist major differences between medical education and training in the United States and Germany. Examining these differences reveals the contrasts between a system that has evolved to nurture new ideas and talent and one that is moribund for lack of change. As outlined by Muensterer, the US-American concept has become one of the most innovative and highly dynamic medical training systems worldwide [10]. This superiority appears, at least in part, to originate from well conceived and standardized residency training programs. Due to a clearly defined duration of residency training, teachers are forced to convey their key messages to the residents and get the trainees ready for practice and board exams. This assures a high likelihood of graduation after a predefined number of years. In sharp contrast, the "German Medical Association" ("Deutsche Ärztekammer") solely defines a minimal duration of training; the key requirement is the recorded performance of a certain amount of operative and non-operative procedures, which usually takes significantly longer than the minimal duration of training (Figure (Figure1).1). Under these premises, residents may have to attend their programs much longer than initially intended in order to become board eligible. While the average US resident performs 1,572 procedures during their five years of residency [11], German residents are eligible to be certified Orthopaedic Surgeons after performing just the minimal amount of 730 operative and non-operative procedures (Figure (Figure1)1) [12]. Moreover, most German residents work under employment contracts which are limited to short periods of time, and thus often do not guarantee a complete residency training at a particular institution. Therefore, the "German system" lacks a solid foundation for effective training of clinical and surgical skills. Rather than reaching predefined goals during each postgraduate year and thereby increasing the individual responsibilities according to the corresponding level of training, these residents have to aim to "please" their superiors in order to obtain a contract extension. In contrast, US residents usually work under a guaranteed full duration of residency at a particular institution, which enables them to focus on their clinical training exclusively. Finally, German residents spend a significant part of their daily activities outside of clinical activities and out of a learning environment due to a massive burden of daily administrative and bureaucratic activities. In the US, most of these activities are performed by auxiliary services and physician assistants, leaving the physician with more time for essential duties, such as medical practice, teaching, learning, and, most importantly, patient care. Following each rotation, US residents evaluate their instructing attendings and vice versa, thus providing both sides with room for criticism and improvement. Evaluations are blinded and must be "360 degrees" with feedback from ancillary health care personnel, physicians and colleagues to insure as an objective sampling of critiques as possible. Each year, US residents have to undergo nationwide "mock" board exams which allow for evaluation of individuals and programs based on national averages thus providing a quality control for the didactic portion of resident training. American residency programs are scrutinized, updated and improved by the mechanism of standardized complete reviews every 3–5 years by a national, speciality-specific, Resident Review Committee (RRC). Not infrequently, programs with significant deficits are placed on probation. If improvements are not made within a set time frame, programs are closed. This is in sharp contrast to average German residency programs, which unfortunately still lack a standardized, periodical quality assessment of residency training.

One of the key differences in the educational approach between US and German residency training is the recognition of the importance of teaching. In the US, second year residents will assist and teach interns, while being taught by senior and chief residents and attendings. In many US Medical Centres, surgical attendings mainly instruct and assist residents during cases. After all, surgery is a skilful craft, which can only be mastered by sufficient exposure, solid caseload and professional guidance by an experienced surgeon. Teaching in North America is considered an honour that is taken seriously. Through the evaluation process of faculty by residents, teaching physicians and their chairman receive direct feedback which is used to insure that educational goals are met. Those not performing appropriate supervision and teaching are often chastised by their departments and their status and salary may be adversely affected. Holding teaching physicians accountable for the performance of their residents develops a patient-centered culture as well as a positive incentive to educate effectively.

I believe that US residency programs represent a highly structured, progressive and innovative educational system. The surgical caseload for US residents is more than doubled – within a shorter time-period of training – compared to the German numbers (Figure (Figure1)1) and with a higher level of supervision by senior surgeons. Thus, by staying in the United States, chances are high that I will be a significantly better surgeon within a shorter time-frame, as opposed to returning back to my alma mater.