An American doctor in Rome [PODCAST]

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“The idea was to try working in Rome for a year and see how it went. This sensible American plan collapsed under the weight of Italian bureaucracy.

Luckily I didn’t investigate every angle before starting off; if I had known the true lay of the land I might not have kept going after that Italian medical license like a donkey after his carrot. I’d have taken a job in some clinic in the Bronx, where I’d be seeing four patients an hour to this day. Instead, I made those steps you can’t retrace: gave up my three-bedroom apartment on the Upper West Side with views of the Empire State Building and the Tri- borough Bridge, and sold my Dodge Challenger convertible to a pinky-ringed Turkish importer-exporter who planned to strip it down to the skeleton of an Oriental low-rider.

Months beforehand I started focusing my Manhattanite efficiency on getting registered in Italy, my Italian husband leading me by the hand through the wilderness of Old World red tape. The first step was “getting my documents together,” an Italian ritual repeated before every encounter with officialdom. Sticking to a list kindly provided by the Italian Consulate, I collected my birth certificate, passport, high school diploma, college diploma, college transcript, medical school diploma, medical school transcript, certificates of internship and residency, National Board Examination certificates, American Board of Internal Medicine test results, and specialization diploma. Then I got them transfigured into Italian by the one person in New York authorized by the Italian Consulate to crown his translation with an imprimatur. We judiciously gave him a set of our own translations as crib notes, tailored by my husband to match the Rome medical school curriculum.”

Susan Levenstein is an internal medicine physician and author of Dottoressa: An American Doctor in Rome.

She shares her story and discusses her KevinMD article, “An American doctor in Rome.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Susan Levenstein. She is an internal medicine physician based in Rome, Italy, and she’s the author of the book Dottoressa: An American Doctor in Rome. Susan, welcome to the show.

Susan Levenstein: Thank you so much, Kevin. It’s really great to meet you in person, so to speak.

Kevin Pho: So we’ll get into your book in a little bit, but first off, can you share your story and journey to where you are today?

Susan Levenstein: Well, I trained in the United States completely. I went to medical school and specialty training in New York: medical school at Mount Sinai, and the specialty training at Montefiore’s social medicine program. At some point during that time I married an Italian, and I dragged him back to Italy. He didn’t want to, but I made him come, and it took me a year and a half before I could get a medical license.

I opened an office. I’ve gone from one office to another since then. My book tells the whole story, and I’ve basically been doing the same thing ever since. I’ve been in private practice. That’s what I spend most of my time doing. I also have had sort of a research non-career in psychosomatic medicine, because I do research on the influence of psychological factors on ulcers and ulcerative colitis, and Crohn’s disease. That’s basically what it’s been, and that’s both clinical and epidemiologic research. And I’m still practicing, even though I tried to retire. I gave up and went back to work. So I’m still seeing patients after 40 years.

Kevin Pho: So we’ll get into more of that journey when we talk about your book later on. I’m curious to see how the COVID pandemic affected Italy, because it did affect it pretty hard, certainly early on. So tell me, what was it like being a physician during the worst of the COVID wave in Italy?

Susan Levenstein: You want to know the truth? I wasn’t here. I landed on March 3, 2020, in the United States, in San Francisco, to do a two-week book tour. Everything was canceled, and we couldn’t leave, because there wasn’t any way of getting back to Italy. So we were in Berkeley for the entire time of the terrible lockdown. We were there for three months. So I was not there during the worst, which means that I was spared both the responsibility of having to decide whether to go into the hospital and see very sick patients, or to suffer, as all of my friends did, having to be basically on house arrest for three months, which the Italians were.

Italy then did very well during the summer, and then had another swing back. Right now, it’s had a little bit of a, I think it’s the fourth wave now. Third or fourth wave, depending on which way you cut it, but it’s not doing anywhere near as badly as the United States is. In the blog post that I just posted two days ago, I put in a couple of the curves so that you can see both the ones in the United States, the ones in Italy, and the one in the U.K., where they haven’t been doing very well there either.

So Italy has done quite well. I can’t say that people have gone back to normal life. But what they have done, mainly, the most important thing that they have done now, is to put in a very strict green pass thing. You can get a green pass either by being vaccinated, and it’s good for a year now. It was going to be good for nine months; now it’s a year. Or by having had COVID, and then it’s good for six months. Or by doing a swab, and even an antigen swab will do, and then it’s good for either 42 or 72, 48 or 72 hours, I’m not sure which.

And all that they have to do is scan the QR code, and it just says yes or no. So they don’t know, whether it’s the person who’s scanning it at a cultural event or a sports event or whatever it is, or work, they don’t know whether you have it because you did a swab or because you were vaccinated or because you were sick. The rules vary slightly from one situation to another.

School is back in session, and teachers are right now being required to present their green pass every day, and if they’re not vaccinated and don’t have a COVID survivor, then they have to do a swab three times a week on their own nickel. So it’s rather heavy, and they’re going to be moving that over also to every other worker in Italy by the end of October.

Kevin Pho: One of the issues here in the United States, of course, is vaccine hesitancy, and that’s really slowing down our recovery. Are you seeing vaccine hesitancy in Italy?

Susan Levenstein: I’m seeing it, but very minimally. I’ve spoken personally to only two or three people who have spoken out against vaccines. I can’t remember the numbers. I keep looking them up over and over again and putting them into my blog, but it’s like a third of what it is in the United States, and it’s basically spread out through the country. It’s not a local thing, which means that it has less impact. So you have more or less the same rate of vaccination everywhere, except in Sicily and Sardinia. Sicily especially has a higher rate of hesitancy and a lower rate of vaccination, and a higher rate of cases, of course.

But one of the things that went on with this, one of the causes of what vaccine hesitancy there is, is that they use AstraZeneca. They’re giving the AstraZeneca vaccine, which is less effective, only to people who are between 60 and 80, 60 and 79. And it’s even less effective in people who are older. The reason why they do this is because, you know, as they did the same thing for J&J in the United States, because of the risk of serious clotting complications. So they get quite a few people, especially in their 60s, who are turning down the vaccine because they don’t trust it.

Kevin Pho: So I’m certainly interested in hearing more about your journey to Italy, and that’s written about in your book, Dottoressa: An American Doctor in Rome. So tell us more about your journey and your book.

Susan Levenstein: When I came here, I really wanted to work in the public system. It took me a year and a half to get my license, and that meant going through the university. I had to sign up at the university. I had to do a kind of an internship. I had to do a doctoral thesis, because in Italy medical school is a university subject. It’s not a practical thing. And unfortunately, there’s the flip side of that, which is that it is very unpractical. In other words, you can graduate from medical school with very, very little contact with patients. It used to be that you could do medical school and a specialty without having any contact with patients. That is no longer the case. You have to do something, but it’s still not at a European or world level.

So I had to go through all of this stuff to get my medical license. And then I really wanted to work in the public system, because, you know, that’s my philosophy. I was really delighted to be able to be in a place that had socialized medicine. It has universal health care. That’s what I wanted to do, but I couldn’t do it, because by the time I got my medical license, I was 32, I guess. I was 32. And you could only get into the hospital until age 35. That was the limit. And generally, there was a five-year wait, when you had to work for free on the wards for five years.

So it was impossible for me to become a public medicine doc of any kind, either in the hospitals or as a GP. So I had to be a private practitioner. I set up a private office, and I’ve been doing it ever since, for 40 years. I have patients who have been my patients for 40 years, which is wonderful. I have that GP kind of thing. I know them. I know their child. I know their grandchild. I haven’t gotten onto the fourth generation yet, I don’t think, but it’s very frequent for me to have three generations.

Kevin Pho: Now, tell me about some of the challenges that you faced over your decades-long career as an American-trained physician in Italy.

Susan Levenstein: Well, at first, I was told that I would never see any Italian men. In fact, I was told I wouldn’t see any Italian patients, because young Italian docs are not considered to know anything. Unfortunately for me, it turned out that I could parlay my being an American and being American-trained into something that was interesting enough that I actually would see Italian patients.

Also, I did office gynecology, and the Italian gynecologists, at least at the time, I won’t say anything now, but at least at the time, they tended to be very rough. One Italian patient after another would tell me it was the first time she had ever had a pelvic exam that wasn’t painful, for example. So I would get these things one by one, and I gradually built up the practice. It was very slow. I saw one patient my first month. I saw four patients my second month. I saw 10 patients my third month. And I managed to move from one office to another, and in any case, it worked out. It worked out with one thing or another.

The challenges that I faced, interestingly enough: I don’t think I faced much of a challenge with being a woman. People sometimes think that I would, because Italy is supposedly a very macho, male chauvinist kind of place, but I don’t think that I faced many problems in that way. In fact, I have quite a few Italian men patients. I always have, since the beginning. So that hasn’t been a problem.

One thing that was a very surprising challenge was to find that I was blackballed from one private hospital because I was Jewish. That absolutely floored me. It was just something that I never expected. When I found out they wouldn’t take me, I assumed that it was because I was incompetent, or, you know, whatever, I was antipatica. But no, it turned out, I found out from an inside source, that it was because I had a Jewish name. So that was really surprising.

Other challenges: The biggest challenge of being a doctor here generally is the lack of hospital backup. Italian medical training is extremely uneven. I mean, there are very good docs and there are very poor docs, and there’s not much in the way of a baseline that you can count on. And the very worst is the hospital emergency rooms, in my experience. This means that, whereas if you’re in America, or you’re in Germany or France or any other first world, so to speak, place, you just tell a very sick patient, “Just go to the hospital,” and they think they’ll be taken care of.

Although I have to say, I have had personal experiences with medicine in the United States where the emergency rooms have fallen down very seriously: people in my family who nearly died because of incompetent emergency room docs in the United States. But still, whatever it is, it’s much better than it is in Italy. And the lack of having that thing behind me is the worst thing.

But in a way, the best thing is having the Italian health system in back of me in general, because there are no barriers to medical visits, there are no cost barriers to medications, and there are no cost barriers to testing. Everybody can get things done on the national health system, which is even more generous than the English one. It’s based on the English system, modeled after it, but it’s more generous still.

Kevin Pho: What’s primary care like in Italy? Because in the United States, and I’m a primary care physician myself, there is a big shortage of primary care clinicians, and the reasons are, of course, varied. There is a variety of disincentives for medical students to go into primary care. What’s the situation like in Italy?

Susan Levenstein: Primary care here is basically a GP. They have GPs. Every Italian is on the national health service, and every person, including many foreigners, is also on it. You all have a GP. You have a general practitioner who runs your case in all sorts of ways, and the GP gets paid on a capitation basis, X number of euros per patient per year. And the training for those people is even more uneven than the training for specialists, and it’s even less practical than the training of specialists, unfortunately. So it’s extremely uneven. That’s as far as the quality is concerned.

As far as the quantity is concerned, Italy has always had a vast oversupply of doctors. I mean, back when I first came here in the ’80s, and throughout the ’80s and the ’90s, anybody who wanted to go to medical school could, if they graduated from a proper high school. The schools were completely packed. It meant that nobody could get any practical instruction, and nobody could get any individual instruction. And they were turning out, I think I said it in the book, as many doctors for about 50 million people as the United States was for 300 million people.

So everybody was unemployed when they graduated. They still have a lot of unemployed doctors, which is something that I don’t think they have yet in the United States. I don’t know. I mean, unfortunately, the training for GPs, it used to be that anybody could become a GP. You didn’t need any special training. Now there’s a specialty program for GPs, called medicina generale. But as I said, it’s even less practical than other training. So they really hand off anything that’s in the slightest bit complicated to specialists of one sort or another.

Kevin Pho: We’re talking to Susan Levenstein. She is an internal medicine physician, and she’s the author of the book Dottoressa: An American Doctor in Rome. Susan, as you reflect on your decades of experience in Italy, for those other clinicians who do want to practice in Italy or other countries abroad, what kind of advice or tips can you give them?

Susan Levenstein: If you want to come to Italy, first of all, you need to have, as it stands now, and I’m not sure, I can’t speak for the entire EU. By and large it’s the same thing in the EU, because everything is supposedly recognized everywhere in the European Union, which of course no longer means England, no longer means Great Britain. But here, one of the prime things that you have to have in order to practice medicine is an Italian passport, which is a barrier that is huge, obviously. Very few people can do it. And I suspect that it’s the same thing all over Europe, although I haven’t looked into it. You have to have EU citizenship in order to be able to practice.

It used to be, and I don’t know whether it still is, that in the U.K. you could get specialty training of some sort recognized, and then you could transfer it over to a continental country. But of course you can’t do that anymore. And one problem is that in most European countries, internal medicine training is 5 years, and in the United States it’s 3 years. This is an insurmountable barrier. I know people who have tried to get around this and failed. So it’s not easy.

But if you have the possibility of coming over, and by now they’re very generous with citizenship, the entire EU is very generous with citizenship. If you have a father or a grandfather or a great-grandfather who was from those countries, you by and large can find some way to get citizenship. It can take a while, but you can do it. But if you do that, my advice, if you were to come to Italy, and I suspect that it’s the same thing every place, if there are barriers, as there were for me, toward working in the public system, is that you bring over enough money to be able to live for two years. Because it took me two years before I was earning anything that could have been like a living.

Fortunately, I was married at the time to an Italian. I’m now on husband number two, Alvin Curran, who is a composer. He’s an American expat like myself. But my Italian husband was working from the moment that we came over here, and so we were able to live. It wasn’t much, but we were able to live off it.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Susan Levenstein: I’ll tell you my take-home message, the take-home message that I have from my book and in my life, and what I tell everybody about Italy and medicine and health, is the following: Medicine in Italy is a crapshoot. It’s very uneven, and they’re very poorly funded. They spend one-third as much on health care as they do in the United States, and their life expectancy is five years longer, and by every measure of health, they are healthier. And the reason is that they have a universal health care system and they have a sterling lifestyle.

Kevin Pho: Susan, thank you so much for sharing your time and insight, and thanks again for being on the show.

Susan Levenstein: Thanks so much. It was a pleasure.

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