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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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