A Mystery Headline In My Inbasket Last Week

“No extenuating circumstances for those who throw mud on the dental profession.”

            - Rome Medical Society Newsletter

Huh? Who was throwing what mud on whom how? I couldn’t resist clicking through. The mudslingers turned out to be . . . real dentists who dishonor the profession by covering for phony ones. This is an old story. Most dentistry in Italy is done privately, not on the National Health Service, which has spawned a whole army of dental imposters – 15,000 or so strong, said to fill a quarter of all the country’s cavities. Usually the pretender is a technician, trained to work on crowns and bridges but dabbling in live teeth on the side, in cahoots with an authentic doc who for a price allows his name to grace the receipts, the prescription forms, and the bronze plaque on the office door. One of my closest friends had a dental technician uncle so she never went to a licensed dentist until she moved to another city at age 35.

The figure of prestanome or name-lender is as deeply rooted in Italian society as that of the Mafia consigliere. Years ago my secretary was inveigled by her first boss into being the official CEO of a shady import-export company, whose shenanigans eventually got her hauled into court. The judge took one look at her neckline and jeans and spat out in disgust, “She’s obviously just a prestanome.”

While name-lender dentists never used to risk more than a slap-on-the-wrist fine, lately the Medical Societies have started upping the ante. Last week’s headline was celebrating the very first time the Rome Medical Society had publically stripped a dentist of his licence, after the courts had found him guilty. This particularly bad actor, charitably left unnamed in the article, had abandoned hand-in-mouth dentistry years earlier in favor of skimming the profits off a chain of quack offices.

But, then, when I was studying medicine in New York it was whispered that patients at my Mount Sinai Hospital had been operated on for years by a neurosurgeon who didn’t have a medical license. As the Italians say, tutto il mondo è paese, everywhere in the world it’s the same village.

Scorecard: Money and Longevity

                                                                   United States      Italy

Gross Domestic Product per capita                $57,467          $30,527

Health spending per capita                             $9,892            $3,391

Life expectancy at birth                                  78.8 years      82.6 years

What’s Their Secret?

The main reason Italians get more bang for their health care buck is that they have a single-payer National Health Service, financed out of taxes. Everyone can see their own primary care doctor and be cared for in the hospital without paying a penny, while medications, testing, and specialist exams require at worst a tiny co-pay. Add in low income inequality and a famously healthy lifestyle, and Italy has more than enough on the plus side to compensate for its medical system’s many flaws.

Learning Experiences

My early professional life was short on patients but long on learning experiences.

Over dinner I asked an anesthesiologist friend of the family what anesthetic was preferred in Italy for childbirth. “Il grido,” he replied, “The scream.” As though it were an explanation he continued, “Remember that the book of Genesis says women shall bring forth children in pain.” Even today, most public obstetrical wards don’t offer either epidurals or painkillers.

I learned from patients’ horror stories that Italian surgeons didn’t use local anesthesia when they sewed up lacerations, or prescribe strong analgesics after surgery; cancer patients got morphine only when death was days away. Patient activist movements have improved things a bit by now, and since the turn of the millennium I can even prescribe the equivalent of Percocet. But those ER docs are still doing their stitching without lidocaine.

I learned from personal experience that a physician who goes to a drug store to buy morphine in Italy, to keep in the office for emergencies, is seen as a drug addict. The first time I filled in a triplicate prescription for 4 vials and handed it to a pharmacist along with my medical license he looked at me crosswise and said they were out of it. So was a second, a third, and a fourth. Being treated like a criminal makes you feel like one, and for years whenever it came time to replace my expired vials I would put on my best clothes, as I would to go shopping on Via Borgognona, and even so my heart would pound. I can only imagine how hard it must be for cancer patients who need to buy morphine for their own use.

Shortly after I moved to Rome Giovanni Agnelli, C.E.O. of Fiat, nicknamed “Rake of the Riviera,” fell and broke his hip. His personal physician, according to the front-page story in La Repubblica, was treating him at home with the leg under traction. I was floored – from what I knew bed rest with traction had been ditched years earlier in favor of immediate surgery, which had patients up and around in days with fewer complications. What I found astonishing was not that an Italian doctor might be behind the times, by now no news to me, but that the richest man in Italy would be under the care of an ignoramus. Lesson: loyalty trumps competence. P.S. A week later buried on page 17 was a one-line report that Agnelli had been flown to New York for surgery.