A Medical Travelogue to Italy: “Dottoressa: An American Doctor in Rome”

When a friend of ours was working for the United Nations, she spent a few years living in Rome—the one in Italy, the one with 28 centuries of history and countless Roman-era antiquities, and also Vatican City, which I understand to be the Pope’s version of Graceland. Yes, I’ve never been.

During her stay our friend found herself a physician, an American ex-pat named Dr. Susan Levenstein.

Let’s say, for instance, that someone was “raised on the New York edge of America by psychotherapist, more or less Jewish, nitpicking, different parents,” then went to Harvard for college, then medical school at Manhattan’s Mount Sinai School of Medicine, and topped all that off with three years of internal medicine training at a hospital in the Bronx, surely the next logical step would be to move to Rome.

That’s what Levenstein did in November 1978, and her book, Dottoressa: An American Doctor in Rome is a finely crafted account of her life and career in “The Eternal City,” so named because we never stop hearing about it.

The hijinks begin with the protracted odyssey of trying to obtain an Italian medical license. Like much of the rest of the Italian government, the Italian medical licensing system is apparently bloated, corrupt, slow, fickle, and very loosely merit based (As in L.A., who you are is who you know—raccomandazione is the Italian term for that). It’s no coincidence that the Byzantine Empire—the eastern half of the Roman Empire that ruled for another thousand years after the western half crumbled—spawned the adjective Byzantine, defined as “(of a system or situation) excessively complicated, and typically involving a great deal of administrative detail.”

As Levenstein chronicles, about the only thing the American and Italian health care systems seem to have in common is, quoting Dr. Randy Newman, “It’s Money that Matters.”

Italy has a national health system that guarantees universal health care—but what kind of health care? The kind that is capable of delivering the highest level of care—if it wants to… but it doesn’t always want to. American physicians are incentivized to do as much as possible for the patient (creating a health care system that is, in comparison to other countries, superiorly expensive while producing mostly average outcomes). Italian physicians working for the national health system are incentivized to do only what is absolutely necessary. The real money is in the private sector, where many of these same physicians work in their afternoons and evenings (and where some physicians also own an attached lab, or MRI machine, etc.). Whatever the system one lives in or under, money always finds a way.

But it cannot all be pinned it all on the whimsical work ethic of Italian physicians. The system is also hobbled by anemic funding, corruption, and Byzantine sloth. The national health system Levenstein describes is a ‘system’ in the loosest terms, one dominated more often by improvisation than by professionalism.

The central irony raised by Dottoressa is this: how can a medical system that can be so comically dysfunctional (Levenstein provides countless examples) produce some of the healthiest people on the planet? Yes, their universal health care covers (sometimes barely) the basic necessities of health and life. But it’s their lifestyle that makes them healthy: scrumptious and healthy food; plenty of physical activity. Their cities, the old ones at least, were designed for people, not cars; alcohol is used in moderation (more precisely, wine as food, not as an inebriant), and strong social networks are the norm. Turns out, humans were meant to live in community; American’s “rugged individualism” often makes people feel ruggedly isolated and alone. And living without the fear that losing one’s job or health will cost you everything appears to be a real stress reducer. This is a physiologic statement: stress is deeply unhealthy. If or how or one builds a societal safety net is a political and cultural issue.

There are other differences too. Italian pharmacists are more independent and “entrepreneurial” than their American counterparts. As Levenstein describes it, a doctor’s prescription is more like a suggestion for the pharmacist; they might dispense what they feel to be a more appropriate alternative. Because Italy’s National Health Service is allowed to negotiate with drug companies (as Medicare and Medicaid are forbidden by Congress to do here in the U.S.), drug prices are much lower.

Italians also have a different approach to doctoring than most Americans. Seeking health care is not viewed as admitting to failure. It is not an embarrassment or even necessarily a misfortune. It can be done casually and with some frequency—like shopping, but you’re shopping for an expert opinion on the aches and pains, the occasional ticklish cough, the rumbling in the stomach etc.. And in Italy, physicians are respected, but they are not gods. They are something closer to a priest or a shaman, an important participant but not the decider. Patients are that.

Levenstein and I are both “internists”—physicians trained in internal medicine, “adult medicine.” Internists are notorious for obsessing about the details, and Levenstein’s Dottoressa provides plenty of those. It’s a medical travelogue of Italy, one that will tell you more about the country than Rick Steve ever could. Carving out a career as a non-Italian in private practice in Rome is no easy feat, but Levenstein did it by building an international clientele, and by attracting Romans of every station who were aiming to keep their medical problems out of the ever-watchful eye of the city, the government, or the Catholic church. Drawing on more than four decades of experience, Levenstein brings to the reader more oddball characters than a Wes Anderson film, so sit down and enjoy the show.