Tuesday, March 19, 2019

A Charming Story Well Told



...that's what Kirkus Reviews calls my book Dottoressa: An American Doctor in Rome, which is rolling off the presses as we speak.😃
Here are some of the specifics that caught the reviewer’s attention:
“. . . One of the first words to learn, she writes, was “pazienza,” or “patience squared,” which is “often invoked as a gentle reprimand for a foreigner’s loss of cool” and “extends beyond the prosaic ‘keep waiting’ to the philosophical.” . . . After finally gaining the official title of Dottoressa, waiting for the sole calligrapher to produce her diploma took nearly two decades. . . . The most interesting part of the book is the author’s descriptions of her alternating admiration and horror at Italian medical practices . . . Doctors almost never touch their patients, but they always listen to every word. Though they write prescriptions, the pharmacist can and will substitute another drug . . . Levenstein also demonstrates how well universal health coverage works. Italians live some of the longest, healthiest lives of anyone on the planet, mostly due to diet, accessible care, and even distribution of wealth. The author gives many illuminating examples of patient encounters . . .”

Saturday, March 16, 2019

Elevator Philosophy (Esprit de l'Ascenseur?)


“Media terrorism”: Winter red alert! It might get cold! –Nicola Bucci
My husband and I took a stroll the other day to the Palazzo Merulana, a new museum housing the Cerasi family’s collection of  Fascist-period Italian art. We entered the elevator along with a well-dressed Italian who pressed “2.” We then pressed “4,” on the chance the museum might have installed a modern elevator, the kind that can keep several destinations in its brain at once. The commoner old-fashioned Italian kind, such as the rickety cage that carries us up the five floors to our own apartment, has to be spoon-fed one stop at a time.
Neither: the elevator flew past the second story, and headed straight for the fourth. An unprecedented variation on the theme of Italian collective transport. All three of us commented with amusement, but our elevatormate took it one step further with a touch of philosophical fantasy, turning the elevator buttons into a microcosm of Italian life: “That’s what life is always like in Italy. He who speaks last wins the argument.”
After viewing a hundred paintings and sculptures, many interesting and some beautiful, I was obliged to hunt down their well-hidden bathroom. On the way in I rubbed shoulders with an Italian lady of a certain age who forewarned: “It’s not very clean” (an understatement). She added, to forestall any suspicions, “I didn’t touch anything.” But, this being Italy, she too felt that wasn’t enough, and added, “We Italians still haven’t reached a level worthy of being called civilization.”
My adoptive countryfolk always rise to one more level of generalization and one more degree of flair. And they never miss a chance to acknowledge – and mock with resigned affection – their own national foibles. Nicola Bucci, a political cartoonist, is a particular genius at putting the brilliant Italian mix of invention and provincialism into captioned images. Now my fellow art-lovers had offered up two strikes in one hour…
Strike three was awaiting me at home, in the form of a friend’s Facebook post about the latest Roman scandal. In 2011 a landowner had paid off a €55,000,000 debt to City Hall by handing over, it was reported at the time, 200 kilometers of precious nickel wire packed into a bundle. This treasure has been sitting in a vault in City Hall ever since, under the watchful 24/7 gaze of armed guards hired for the task. Until a few months ago when city officials, tipped off about a fraud by the same characters in northern Italy, opened the vault and determined that whatever it is that’s rolled up in that stash it’s worth nowhere near what was claimed – maybe €20,000 at the most. Less, I’d guess, than what they’ve been paying every month to those rent-a-cops.
The heights of fantasy in the depths of financial scams. I love Italy.
*******
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Friday, March 1, 2019

An Extract From My Book Published As An Article


I am pleased (and, frankly, just a mite proud) to let you know that a brief extract from chapter 16 of my upcoming memoir – Dottoressa: An American Doctor In Rome – has been published, as “Endings, Beginnings,” in the Perspective section of The New England Journal of Medicine, which is generally considered the world’s top medical publication. This piece, which is mainly about the impact of one death on my medical practice, can be accessed free online by everyone. It's much more sober than most of the writing that you’ve been used to, pretty heavy in fact… I hope you’ll appreciate it anyway. To my amazement, it’s been read  by about 5000 people so far, not counting subscribers who received a paper copy in the mail!
The book itself now has a scheduled publication date, May 21st, less than three months away, and it can already be preordered in the States either through my publisher or at Amazon, and in Italy or elsewhere at Book Depository, who offer free shipping worldwide. Consider passing the word.

Monday, February 18, 2019

Another Bright Idea From the Five-Star Party



by Goya
The same Italian government dreamers who brought us the Great Leap Forward in medical education I talked about in my last post – the ones who suggested that the doors of medical school be opened to all comers and that postgraduate education become optional – are running a new idea up the flagpole, this time for teachers. Five Star policy wonks have come up with the idea of offering them Continuing Education classes in a new field: exorcism. Yes, the Five-Star Movement’s Minister of Education is allowing educators to earn points valid for higher pay and promotions by taking 40-hour courses, taught by priest expert in the casting out of demons. Any teacher willing to shell out €400 ($452) can now learn both the theory and the “correct practice” of prayers that might be useful at least, one hopes, to keep a few little devils in their seats.

But why stop at teachers? Doctors would surely be even better students of the White Arts. There’s always been a subset of Italian psychiatrists who boast of being able to tell which patients’ bizarre behavior is from mental illness and which is the handiwork of Satan. Until now they’ve had to hand over the possessed variety to priests for the performance of demon amputation. Perhaps in the future my colleagues and I will be able to graduate from mere diagnosis to treatment while fulfilling our Continuing Medical Education requirements, by learning to chant for ourselves the proper invocations against the cursed dragon and his diabolical legions.

You can already earn Continuing Medical Education credits in Italy by studying contract bridge. A practical class in the treatment of demonic possession wouldn’t be much of a stretch.

By the way, this mishegoss is not special to Italy. According to an in-depth Atlantic article just two months ago, half of Americans believe in demonic possession, and the exorcism business is booming.

*******

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Thursday, February 14, 2019

Pack 'Em In


Lecture Hall at an Italian Medical School, 2014

When I first moved to Italy, any high school graduate who thought they might like to be a doctor had the right to give medical school a whirl. Because of this open admissions policy, ten times more physicians were churned out each year than the country needed. And because there was no way those hordes of students could get individual attention from their teachers, and far too few bodies for them to learn on, you could graduate from med school without having ever touched a patient. Literally. Italian medical training was so notorious that when the European Union started recognizing degrees and specializations across borders, Italy risked being the only country excluded.

The threat of that humiliation goaded Italy to begin a minor revolution. By the turn of the century a system of selection for medical school had been introduced (based on a multiple-choice test), freshman classes had been slashed by 90%, and students were starting to be taught at patient bedsides instead of only from books. Italian medical training was making giant strides toward joining the rest of Europe.

Now, twenty years after Italian doctors began their Long March from laughingstocks to world-class clinicians, the Italian Health Minister, Giulia Grillo—a physician previously known mainly for waffling on the need for vaccination—has been crusading to turn back the clock by bringing back open admissions for medical school. No more tests. No more selection process. Anybody who made it through high school would again be welcome. Come one, come all!

Dr. Grillo, from the Five-Star Movement, has even added a sour cherry on top: the downgrading of postgraduate training. She points out, correctly, that due to sloppy planning Italy has gone from too many prospective General Practitioners to too few, and trains far too few specialists in emergency medicine to keep hospital Emergency Rooms properly staffed. Her proposed solution? Stop requiring docs hired for those jobs to have any residency training. Instead, she says, hospitals should be able to employ anybody with experience, such as night coverage (Guardia Medica) on the National Health Service, assuming they’ll have picked up their trade by osmosis. Even worse, she’s suggested maybe those ER docs and GPs could be hired fresh out of medical school. Anywhere in the world that would be a mistake, given the complexity of modern medicine, but in Italy—where medical school is still relatively weak on the practical—it would be madness.

Already many young Italian medical graduates flee the country, headed for nations where they expect superior specialty training, higher stipends, and eventually a better chance at real jobs. And already Italian specialty training is uneven, turning out specialists whose levels of competence range from superb to iffy. If even that spotty training is turned into an optional, with self-taught doctors handling heart attacks and accident victims . . . poor Italy!

Pardon my rant. I’ve never been good at buddhistic acceptance, and the coronation of Donald Trump reset my indignation threshhold even lower. By now even a considerably less dangerous Italian Minister of Health can trigger it.

P. S. The picture of a medical school lecture hall at the top of this post was from 2014, when the admission process was highly selective. Imagine how packed those halls used to be when ten times as many students were enrolled, and how they will be again if Dr. Grillo gets her way.

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Thursday, January 31, 2019

United We Fall


drawing by Suzanne Dunaway
Doctors have professional organizations in both Italy and the US, but their purposes are light-years apart. Where the American Medical Association is basically a lobbyist for doctors, the equivalent on this side of the Atlantic, the Ordine dei Medici, is more like a police force. I’ve visited their Rome office exactly five times, and I remember every one:


 1)    In 1979, to find out how to get my American internal medicine specialty recognized. That didn’t take long: “You can’t.”

2)    In 1998, to peddle an old pulmonary function testing machine by tacking up a For Sale notice on the Ordine’s cork bulletin board. No buyers materialized, but some employee with nothing better to do noticed the words “Diplomate, American Board of Internal Medicine” on my letterhead, and sent me a registered letter enjoining me to remove them. Turns out you’re not allowed to mention foreign specializations. I took the appropriate action for any old Italy hand, i.e. I did nothing whatsoever. The ABIM is still on my letterhead – they never followed up.

3)    In 2004, to buy passes to drive into the center of Rome, a prerogative reserved for residents and for docs on house calls. We had always had free dashboard permits, but suddenly City Hall announced it would start charging for the privilege. I lined up at the Ordine dei Medici along with hundreds of other colleagues dumb enough to take the initiative seriously, forked over a 10 euro note that they said would be good for ten single entries, and received a receipt that stated the passes would come in the mail. Did any passes come in your mail? No? Well none arrived in mine either. Good thing I hadn’t thrown out my old dashboard permit.

4)    In 2005, to try putting my first Aventino Hill office on a more formal legal footing. My two partners and I partners trooped over to the Ordine for an hour-long briefing from their lawyer, taking careful notes on his advice. Fortunately we didn’t act on it – we learned later from unimpeachable sources that he had been wrong from A to Z.

5)    In 2010, to defend my second Aventino Hill office, soon after we moved in. Our neighbors sicced the Ordine on us, after sending around the Carabinieri, the Health Department, and the Lazio Region, as part of their unsuccessful campaign to kick us out of the building. (The one agency they never snitched to was the IRS – fearful of drawing attention to their own tax returns?) The Ordine called us in for interrogation, and then mailed a ten-point accusation in impenetrable legalese to which we promptly, humbly, and painstakingly replied. A year later, when we hadn’t heard back, we phoned to make sure they’d dropped the charges. No, they just hadn’t gotten around to looking at our letter yet. They finally did read it, and grant their absolution . . . in 2013.

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Saturday, January 26, 2019

An Interview


I enjoyed answering Claudia Landini's queries about Dottoressa: An American Doctor in Rome, the book that, as you know, is coming out in just four months. You might like to check out her super questions and my attempts at answering them at her website, ExpatClic.

Monday, January 14, 2019

Home Sick In Rome


drawing by Suzanne Dunaway
After moving to Rome it didn’t take me long to figure out that my friends’ grandparents had all been either peasants or aristocrats, and that for the latter classes a doctor was expected, if illness struck, to come when called. Like in the 19th century, when they used the back entrance – the doctor was a tradesman, like a carpenter only cheaper. Read some short stories by Chekhov, whose day job was General Practitioner, and you’ll get the idea.

Once in the ‘90s, over dinner at an oak table on the high-ceiling piano nobile of a baroque palace, under an oil portrait of my hostess’s granddad, a new acquaintance tossed a spanner in the works of a previously pleasant conversation: “Do you make house calls?” Which led to twenty minutes of shifting uneasily in my seat while my highborn tablemates complained about how difficult it is nowadays to find a doctor willing to come to your place when you have a sore throat.

When Italians are ill their rest is sacrosanct. I’ve seen many a workplace dynamo relish the theatrics of the sick role, unashamed to hide under the covers safe from the menace of outdoor air. It’s easier, of course, when you have a right to six months of paid sick leave…

drawing by Suzanne Dunaway
I hear house calls have been making a small comeback in the States. They never went out here, though as the years have passed and I have reached do-not-disturb maturity fewer patients expect me to make one personally. One benefit is that setting up an elaborate sickroom in the home is a breeze. Laboratories are happy to send around a technician to draw blood, you can enlist your aunt or your portiere to give injections, some young doc will be willing to come and hang an intravenous drip if one is needed, and a radiologist will trot in with marvelous briefcases that open out into x-ray machines – in pre-digital days, they’d hang up the films over the bathtub to dry.

*****

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Monday, December 24, 2018

My Life As an LMD


drawing by Suzanne Dunaway
Italian public hospital doctors tend to despise general practitioners, resent private physicians, and defend their realm from both. One time a patient came to my office in obvious need of immediate abdominal surgery. I shipped him off to the Emergency Room with a referral letter, heard from the family that some kind of operation had been done, tracked down the surgeon on the phone – and the guy refused to tell me what he found.
During my residency in New York City hospitals our attitude wasn’t much different. Our self-importance was reflected in the sneering phrases we used to refer to outsiders. “Saint Elsewhere” was resident slang for a humbler hospital that had, in our opinion, mishandled a difficult patient and then punted him or her over to our training institution for us to patch up (New York hospitals’ saints included Anthony, Barnabas, Clare, Elizabeth, Giles, Joseph, Luke, Mary, Vincent, and a whole host of Johns).
“LMD,” short for “local medical doctor,” referred archly to a patient’s outside physician, always presumed to be an idiot. A typical emergency room medical history: “3 days ago 105º fever and difficulty breathing. LMD prescribed aspirin over the phone.”
Being on the other side of the divide, now that I’m an LMD myself, isn’t easy. When I’m trying to get an update on a patient of mine who’s been admitted to one of Rome’s public hospitals, I do everything to avoid the categories of either competitor or smarty pants. The best results come if I have a friendly colleague who works in the hospital go and spy. When there’s no inside informant for me to turn to, I’ll make diplomatic phone calls attempting to cajole the hospital docs into giving me information, on grounds ranging from the patient’s embassy has asked to be informed, to the relatives are pestering me from the States, to the patient doesn’t speak a word of Italian. Whatever I can think of.
This can lead to dangerous pussyfooting around which at least once, back in the ‘90s, led to dire consequences. I gave in to the pleas of the worried wife of one American tourist, who was in the Santo Spirito Hospital’s intensive care unit for chest pain, and agreed against my better judgment to make a trip to the hospital to take a look. Once there I played super-nice with the house physicians to avoid offense: I merely glanced at the blood test results, I read the x-ray reports without looking at the actual films, and I listened respectfully to the staff’s reassuring conclusions. I backed the hospital docs up all the way, and told the patient’s wife that since he hadn’t had a heart attack he'd surely be able to fly home in a couple of days.
Well, that patient died ten hours later, of a ruptured aortic aneurysm, when a segment of the body’s main artery has ballooned out as it exits the heart, and bursts. This is a major emergency that can often be diagnosed or at least suspected from a simple chest x-ray, and could have been cured by surgery. I was devastated. When a fit of masochism sent me back to the hospital the next day to take a look at the x-ray I had skipped on my previous trip, the diagnosis seemed obvious. But without knowing the answer ahead of time would I have gotten it right just by looking at the film? Was the patient’s death chiefly the fault of the hospital doctors’ failure to make the diagnosis, or was it my own fault for the insecurities that had made me suck up to the hospital staff and the family rather than be thorough? Writing about it now 20 years later I still shudder with guilt.
*****
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Wednesday, December 5, 2018

Warning: Politics May Be Bad For Your Health


Patients jammed into an Italian emergency room corridor
Americans who knew something about Italy used to nod knowingly when I’d tell them the National Health Service was going from bad to worse, saying: “Ah, that bastard Berlusconi.” Not so. Silvio Berlusconi, small-minded as he may have been as on-again-off-again Premier between 1994 and 2011, did relatively little harm to the health care system; his political program never went far beyond (1) keeping himself out of jail and (2) getting to paw lots of women, the younger the better. By the time Angela Merkel and the European Bank maneuvered the Italians into giving Berlusconi the boot, he had made only a few timid cuts in public medicine. It was Merkel’s more respectable buddy Mario Monti, the sober economics professor she and the other Europeans installed to take over from Berlusconi as Prime Minister, who proceeded to force austerity with a vengeance on Italian regions in deficit, which meant most of them. Poof! there went the hospital beds, and the staffing, leaving patients amassed on gurneys in emergency room halls. Mario did more damage to ordinary Italians’ health care in one year than Silvio had in seventeen.
Seven years down the line, there’s been another game-changing shift in Italian politics, including medical politics. This time, though, the protagonists are dangling pledges to spruce up the National Health Service rather than vowing to undermine it. The right-wing League and the no-wing Five-Star Movement, the two parties currently – and improbably – sharing power, have made rosy joint promises to restore funding for the public medical sector, fight corruption, and improve services. Plus promising their constituents everything from earlier retirement to a guaranteed minimum income.
But it’s all pie in the sky, based on a magic trick. At the same time as the Five-Star people campaigned on beefing up the welfare state, their buddies in the League were swearing to slash taxes for businesses. When they cobbled together a government, each party stuck to its own promises, despite the glaring contradiction between taking in less and spending more. European Union economic authorities did some arithmetic and turned thumbs down. The Italians have so far dug in their heels. Who will blink? Will the National Health Service ever receive that badly-needed infusion of cash? At this point it’s anyone’s guess, but I wouldn’t hold my breath.
*****
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Sunday, November 25, 2018

The Road To Redemption


drawing by Suzanne Dunaway
Stay with me on this one, it’s worth the trouble – all you need to know about Italy in a single story.
ENPAM (Ente Nazionale di Previdenza ed Assistenza dei Medici), the physicians’ pension fund, allows its members to pay in retroactively to cover the time they spent at university. This riscatto della laurea, “redeeming your degree,” lengthens your pensionable working life by six years and yields a healthy boost to your pension.
In one of those mysteries of Italian bureaucracy, ENPAM assured me early on that they would let me redeem all six years of Italian medical school, even though I’d only actually been enrolled for 11 months (taking courses not required for my American MD). I could never quite afford the riscatto, though – the cost crept up year by year slightly faster, in proportion, than my income.
In 2004 an office-mate tipped me off that there was a half-price sale on the riscatto della laurea. I leapt at the chance, and headed off for ENPAM central, a vast labyrinth. A receptionist pointed me toward the riscatto office, and after hiking up one corridor and down another for ten minutes, asking directions repeatedly along the way, I reached a corner room with the right number pasted outside. There a kindly official sat me down, patiently explained the riscatto, confirmed that the cost was temporarily 50% of normal, calculated my reduced monthly payment, handed over the sheet of paper with his scribbled calculations, and helped me fill out the application. After I had signed, he kept it.
Three months later my first bill arrived, for exactly double the figure he’d written down, and more than I had in the bank.
I phoned ENPAM the next day. The employee who fielded my irate call said the higher bill I’d received in the mail was correct. Half-price sale? What half-price sale? There had never been, nor could there ever be, such a “sale.” Who on earth had told me otherwise? I described the location of his office and the position of his desk. Long pause. Then, “Aaa, allora si capisce,” oh, that explains it. The helpful gentleman in question, she volunteered, had been off on prolonged sick leave and since returning to work was not quite right in the head…
In other words: an employee known to be incompetent had been allowed back on the job. Italian compassion. Once back, he was permitted to hand out major-league misinformation. Classic pressappochismo (literally more-or-less-ness, or sloppiness). And his colleague, gifted with Italian courtesy, had no compunction about telling a stranger all about it over the phone. A bad joke, with a worse punch line: the application I’d been misled into filing and then had to cancel counted as my once-in-a-lifetime chance at the riscatto. I was doomed to a pension without benefit of those six extra years.
*****
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Sunday, November 11, 2018

Tests of Character

Drawing by Suzanne Dunaway
“Mother And Baby In Intensive Care After Doctors' Violent Brawl In Delivery Room Delays Birth”
Laura Salpietro, 30, had been rushed to hospital after her waters broke, but as she lay on a bed in agony, doctors argued over whether to deliver her first child naturally or by caesarean. Amazingly, the row then became violent, with punches thrown while her horrified husband Matteo Molonia, 37, looked on, pleading for the medics to stop and help his wife.
Daily Mail, byline Sicily, 2010
                                                * * *
The Italians I have known and loved are fun, funny, cynical, flirtatious, spontaneous, determined not to let their work interfere with their lives. It occurred to me, as I waited for the anesthesia to turn out the lights, that none of these were qualities I wanted when it came to my health care.
– Holly Brubach, New York Times Sunday Review, 2014

We all know what doctors are like. Compulsive sons of bitches, anal retentive, detached, perfectionist, tough on themselves, insufferable with others, models of dogged stick-to-it-iveness and preternatural calm. In Italy? Some yes, some no...
*****
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Wednesday, October 24, 2018

Skates, Spaldeens and Buster Browns


When I was a kid we lived in the Pomonok housing project in Flushing, Queens, a half hour’s subway ride from Times Square, long before the projects turned dangerous or the borough went Asian. The car-free playground just out the door always offered a glorious assortment of games, and after school I’d play punchball with a spaldeen, run bases, shoot marbles, play jacks, or jump rope with a clothesline chanting “Policeman policeman do your duty, Here comes Susie the American beauty” until my father whistled out the window or it was too dark to catch the ball, whichever came first. My usual means of transport was clamp-on roller skates.
Jack the Ice Cream Man, a neighborhood institution, didn’t only sell popsicles and chocolate marshmallow push-up sticks, he also organized races and yo-yo contests, with bird whistles and glow-in-the-dark plastic skulls as prizes.
Everyone stayed home from school on the Jewish holidays, even the black kids, with the exception of me and a few other red diaper babies unfortunate enough to have principled left-wing parents. I remember two ways a marginally better-off kid might lord it over the rest of us: to own a baseball glove, and to play potsy (that’s Queens for hopscotch) by tossing a red checker instead of the standard-issue bottlecap onto the squares.
There were other tomboys on the playground, but I was the only one who convinced my mother to let me wear boys’ shoes under my dresses – in the fifties that meant not sneakers but Buster Browns with leather soles – so I could run faster.

We had a piano for my father to play Bach, Mozart, and Count Basie. At age four I sat down on the stool like he did and slammed my open hands on the keyboard expecting music to come out – I still remember my shock at the cacophony! I got to start piano lessons afterward, learning to read notes about the same time I learned to read words.
In 1954 I was scheduled to be a guinea pig for the Salk polio vaccine but I hated injections (I still do, that’s why I’m so good at giving them). My mother spent hours giving me make-believe shots with a bobby pin so I wouldn't pull my arm away at the moment of truth. She told me I had to get used to needles because I would need them to take away the pain of having a baby – an issue fresh in her mind since my little brother was just two years old. At the last minute I caught a cold and didn't get the vaccine after all, disappointing everyone except myself.  When they taught us in medical school that some of those first batches hadn't been adequately inactivated and had given lots of kids paralytic polio, I took it as a sign of personal grace.
My health suffered no serious threats. Perpetual scabs adorned my knees – when my mother once hinted there would come a day when I would no longer have them, I didn’t believe her. I landed on my coccyx roller skating and couldn't sit down for a week, I split my chin open showing off at potsy, and there were warts to paint, but no broken bones and no appendicitis. I even managed to hang on to my tonsils.
Pomonok has changed some, but – according to one contented denizen recently – “Residents are born, raised, and never leave here!” So next time you hear anyone badmouthing “the projects” maybe you’ll remember my project: kiddie heaven.
*****
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Wednesday, October 10, 2018

Convicts, Cons, Cosa Nostra


drawing by Suzanne Dunaway
In Italy as in Tony Soprano’s New Jersey, the garbage business is traditionally in the hands of the Mob.  
The ubiquity of organized crime is no surprise when it comes to Italy's South, cradle of the Mafia and its regional offshots. Nobody’s shocked to hear that the Calabrian ‘Ndrangeta runs hospital kitchens and has the corner on artificial limbs. It’s par for the course if Goodfella funeral directors wander the hospital wards in Naples with impunity in search of imminent cadavers to snatch, or if Sicilian regional administrators let public hospitals deteriorate so their Mafioso friends can build private ones. But when we read reports of Mafia-owned businesses getting the contracts to build and renovate hospitals in previously off-limits northern cities like Verona, Savona, and Milan, I for one find it frankly amazing.
Convicted Mafia bosses are always getting assigned to house arrest instead of prison on the grounds of ill-health. Failing which, they arrange transfers from jail to cushy private hospitals on trumped-up medical excuses. One easy trick is to buy off a surgeon to perform a biopsy and then switch the histological slides, so the pathologist will diagnose a healthy boss as having cancer. In my favorite case the gentleman had been passing himself off as a kidney dialysis patient. When a suspicious judge sent around an inspector to check with his own eyes that the near-death lab specimens came, indeed, from the man of honor, cooperative doctors rigged up a bag containing the blood of a real dialysis patient on the boss’s back and ran a catheter down through the sleeve of his hospital gown. That way a nurse who was in on the scam could by a little sleight of hand draw a diseased blood sample, in front of the inspector’s eyes, from the plastic tube instead of the vein. 
 *****
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Monday, September 24, 2018

Bargain Hunting


drawing by Suzanne Dunaway
My patient Gayle lived hand to mouth with an Italian mechanic boyfriend, her sole income selling homemade preserves at the weekly village market. She decided to consult me after giving up on her National Health Service General Practitioner: she’d been experiencing gnawing abdominal pain for months, then started having bloody diarrhea. It was obvious that she needed colonoscopy to figure out what was going on, and fast, but how was she to get one? Her local public hospital had an eight-month waiting list, and she couldn’t afford €900 to have it done in the private clinica I usually recommend.
Gayle asked around and found a cut-rate private operator who quoted her €250. I turned thumbs down at her doing such an invasive procedure with someone I didn’t know – I’ve seen too many colonoscopies gone wrong. Sometimes the doctor got only halfway up the colon and turned back. Other times he or she saw polyps but left them in place instead of removing them, or omitted biopsies that need doing. In the worst case, a hole was poked right through the bowel wall.
Next I asked my trusted gastroenterologist colleague whether he could get her hospitalized on the public ward where he worked. He rolled his eyes and told me his hospital was so short of beds that an ulcerative colitis patient of his was parked at that very moment in the Emergency Room hallway with a high fever, passing bloody diarrheal stools every hour, waiting for a hospital bed to open up and in the meantime getting no treatment at all. No chance that my patient, who was sick but not at death’s door, could get admitted.
For decades, there’s been a tug-of-war on between full-time National Health Service hospital doctors who want to supplement their salaries with private practice, and governments that aim to keep public medicine strictly public. An uneasy compromise lets hospital docs see paying patients, but – theoretically – only inside the hospital. This has been dubbed intramoenia, Latin for within the walls. If you get a colonoscopy on the public system you’ll pay next to nothing, but unless you arrange it a year ahead of time you’ll feel every painful twist of the tube. If you do your colonoscopy privately in the same hospital, with the same gastroenterologist, in intramoenia, an anesthesiologist will be glad to knock you out for the duration.
In their battle to hold on to outside offices, the physicians have found strange bedfellows in the left-wing hospital workers’ trade union, which opposes on principle the mixing of public and private medicine on hospital grounds. Both groups have been appeased by a sleight-of-hand redefinition of “hospital grounds” that can stretch to include offices anywhere in town…
Back to Gayle. My trusted colleague eventually came up with a splendid solution: he referred her to his own trusted colleague who did the exam on intramoenia three weeks later for €450, about what Gayle and her boyfriend could scrape together. The diagnosis? Crohn’s disease, which now that it had been diagnosed could be treated perfectly well in the public system where she doesn’t have to pay a penny. Much of my professional life is spent helping patients run this kind of daily slalom between public and private medicine. Quite a job in its own right.
*****
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