A Neurologist in Italy

by

Frederick Deutsch M.D.

Introduction:

These are several brief (maybe not so brief) chapters from a book I wrote about my life that I think my neuro colleagues would find interesting. I’m in the process of looking for a publisher. I do hope that those with delicate ears on the neuro list will not be offended by my explicit language. Although some may not agree, I think it adds some color. I’m really not writing for a professional crowd. Also, I’m sure that the grammarians on the list would take issue with some of my sentence structures. I decided to write what I think is in a less formal manner and I ignored a lot of the mistakes that pop up when I click on grammar check. Please take into consideration that a lot of what I have written is presently anachronistic. Thanks for your interest.

Chapter 1: Open for Business, "The Doctor Is In"

A cliche’ from the Peanuts strip. It was November 1976 in Vicenza. I found office space during a previous trip I made to Italy while in the Army at Frankfurt. It was in a small multi-specialty complex in the center of the city. Looked like a good location. The office was small but enough space for a reflex hammer and safety pin. Those were mainly the armamentarium for a neurologist. The receptionist was beautiful and she told me she would get the word out regarding my availability. Who would not look and listen to her? I put up my shingle along with the other professionals on the wall outside the building. I waited for the herds of patients but only got a few strays.

I should have done more research regarding what private practice was at that time in Italy. There was no quota for entrance into medical school. The whole country was overloaded with physicians, in fact, there were about 70,000 unemployed or under-employed. Most of them were not specialized, just neo-graduates looking for a job. I thought that being specialized I would not be part of their competition and for the most part I wasn’t. But, there was a general atmosphere of cutthroat competition. Just too many physicians in all specialties. I didn’t know, and I sure as hell should have, that there were already 7 practicing neurologists in Vicenza at that time for a population of about 120,000. Stateside statistics at that time, which I still think is valid, is that one neurologist for 100,000 people is the right match, right for a productive practice and right for patient care. Obviously, only a small fraction of the 100,000 have neurological problems or need evaluation. I knew some of this but thought than an American trained specialist with a foreign name would be attractive. Italy was not at all xenophobic or anti-Semitic. No one there would associate me with being Jewish. My last name is so very German. And the Italians loved the Germans. I could never figure out why after what they went through during the war. Maybe it was more envy than love. It was quite obvious that, after the war, Germany was leaving Italy in the dust with progress it made in all fields. So, I became the German doctor as far as everyone was concerned. I thought that maybe it was better that way, better for business. What I didn’t know is what the common knowledge was of what a neurologist does. For years, it was always neuropsychiatry. It had recently split and seems that the public relations people failed; the word seems to have never gotten out. For patients with emotional problems, it seemed saying that going to a neurologist was much more acceptable than saying they were seeing a psychiatrist. Apparently wanting to avoid social stigma. So, the practicing neurologists were really doing what I call “little league psychiatry”. They would listen to patients and then write a series of prescriptions. To me, this was professional prostitution and I never accepted becoming a hooker. Psychotherapy was unheard of. The real neurology was done at the main provincial hospital. If a patient was hospitalized, care would be taken over by the hospital staff. Following a hospitalized patient was impossible. This I knew but thought that I could satisfy myself doing strictly outpatient work at my office. I wasn’t looking for wealth; just enough to live comfortably. And, I had enough of bureaucracy and on-call obligations over the previous 8 years. Malpractice insurance was ridiculously cheap. Only about $300 a year!

So, my first patient was a young guy who told me that his problem was that he planned to get married the next day and was having second thoughts! I looked at him and tried to think what the fuck this has to do with neurology! I didn’t know how to proceed; after all, he did pay for his visit. I felt that I did have to say and do something. I asked him if at least he had a headache. No luck! No headache! I asked if he was fainting. No luck again! No fainting! I asked if anyone in his family had neurological disease. He didn’t know what that was! I gave up! I told him to go find a psychologist, or a priest, or a friend, or his mother! I didn’t do a damn thing for him and told him to get his money back for the visit. Not a good beginning. Obviously I couldn’t tell him to go see a psychiatrist since that was what he was avoiding in the first place. Wait, it gets better. The second patient I saw was a 12-year-old girl who came with her mother. After a detailed history and examination, it was quite obvious to me that she had a seizure disorder, epilepsy, absence spells. I ordered all the necessary tests (blood tests, EEG, skull X-rays, etc., etc.) and ordered the proper medication and learned later on that she did very well. From a professional standpoint, things started looking better for me after this second patient. But, the third came and I went back to square one. She was a pretty 20-year-old girl. She was very nervous and embarrassed and it took forever for her to tell me what her problem was. I was patient and coaxed her along. She finally turned red and told me that when she has sex with her boyfriend she has an immediate orgasm and thinks it’s all over. She stops and her boyfriend gets pissed. He apparently was just getting started. I thought that, for her, isn’t she lucky! I told her that women could have multiple orgasms and that she shouldn’t stop after the first. She told me that she never heard about that. She seemed so happy and thanked me so much. I did take her money! The next patient put me behind square one. He was a 30-year-old office worker. He told me that he gets an erection when he is near a cemetery! In fact, he finds himself going to cemeteries more and more recently! Necrophilia! I did know that he had a serious problem. I spent the next hour trying to convince him to see a psychiatrist, a good psychiatrist. He initially resisted but I told him what neurologists do and what psychiatrists do and that I think that his problem is serious but can be helped with proper management. I think he got the picture. I gave him a referral. I never knew if he followed through. I didn’t do a damn thing for him neurologically, but I do think that I oriented him towards proper care and it was a lot of work. I took his money! However, I wanted out of this stuff. If this was private practice in neurology, I thought that maybe I should go and wash windows! The next day I went to the main hospital and spoke with the director of the neurology division. I knew that I could never get a position there because it was government run and I was not an Italian citizen. Also, there were no positions open. I wanted to be in neurology land and told him I would work there for nothing and see what happens. He was only too happy to get free help. I made the right choice because working there for several weeks and meeting colleagues, the world opened up for me.

Chapter 2: Teaming and Mainstreaming

After several days doing pro bono work at the Italian hospital, I became friendly with one of my colleagues, a neurologist, from Naples. We became friends and played tennis together on several occasions. I invited he and his wife for dinner. One word led to another and he told me that he was doing consultations on the side at a clinic for neurologically disabled children and young adults. The clinic was a private daytime residential setting with outpatient service. The place was situated 32 kilometers from Vicenza and my colleague told me he was tired of traveling there 3 times a week. I told him, “Have hammer, will travel!” He arranged for me to take over. It was a roaring success. Everyone there loved me. I did have some experience in pediatric neurology from the Army hospital while at Frankfurt. Once a week we would hold a combined clinic with a pediatrician, psychologist, child psychiatrist, physical and occupational therapist and social worker. I did this for 3 years. I found the same setup at this new place. The pathology was more than interesting. I never knew there were so many neurologically impaired children in such a limited area. In addition to outpatient referrals to that clinic from local physicians, schools, church and parents, I also made house calls with the social worker, a nun, to many remote places up in the hills. I was appalled seeing how many handicapped children were hidden in their homes because the parents were too embarrassed to have them seen. The pathology was phenomenal. I initially had some trouble with the local dialect but got into it pretty fast. My social worker nun was great. Such a help and so important as a breakthrough dealing with ignorant and resistant families. Families probably wouldn’t have opened the door to a physician or teacher or a municipal social worker if they knew it was about their sequestrated child, but, the door was always open for a nun and she was the greatest sidekick. She told me that once she got information from a teacher at a small school way up in the hills that she had a child in her class who was disruptive and couldn’t sit still and that attempts to contact the parents failed. The nun went to the house to talk to the parents in a remote mountain area. When she got there, she found the child locked in a rabbit cage! She told the parents that there was probably another way to deal with the problem. They opened the cage and let the child out. I wonder who was happier, the kid or the rabbits. The nun social worker and I developed a very close relationship and eventually, during our conversations, she found out I was a Jew. I knew it would not matter at all. So, there I was in a most satisfying setting. Three half days a week initially. The money wasn’t great but at least something was coming in. This was already late November. This clinic had a smaller branch on the other side of the mountain. They asked me if I would cover that one too. There was already a neurologist there but at that time he needed some time off for something I don’t remember. It was supposed to be for 2 months. I grabbed at the opportunity and now it was 5 half days a week and a little more money. I found the same staff setup there and, they too, loved me, and they all continued to love me at both clinics for the next 10 years!

I still kept my office availability in Vicenza. But, I wanted to see if my beautiful receptionist also had beautiful brains. She did. I told her to filter any patient that would request an appointment with me for “real” neurological problems. The volume at the beginning was very small and I knew that with a filter it would be smaller. I didn’t care. I was working a lot just the same and doing what I considered most interesting and professionally satisfying. I really wanted to do only adult neurology in the first place but there just was not enough volume to make it feasible to pay the rent and feed my family.

So, by late December 1976 I was working 5 half days a week, traveling a lot and getting an occasional filtered patient at my office. I still had some free time and needed more money. I was using a supplement from my savings and it was getting dry. I had to find something else to meet expenses and stop the drain from my backup funds.

A newly passed law that Italy fucked up saved me. At that time there were special schools for handicapped children. The new law mandated closure of all these schools nationally and ordered transfer of all the children into public schools. This is what we, in the States, call “mainstreaming”. The philosophy behind it was commendable. Take the kids out of segregation and put them in with normal children. However, the enactment was a disaster. The public schools, particularly teachers and custodians, went bonkers. From one day to another they found severely handicapped children in the classes with absolutely no support. Children with Down’s, spasticity, psychosis, physical handicap from birth, emotional disorders and all needing special care with no one to provide. No one to wipe their noses or take them to the bathroom. More important, no one to facilitate schoolwork. The Italian politicians didn’t think of it! By the beginning of January there was a national crisis. The public schools were supported for logistical needs by the local city or provincial governments. An outcry came from the schools to the local governments to do something. They did. They sponsored, and paid for, teams to facilitate mainstreaming. They could not provide specialized teachers since that was the responsibility of the Ministry of Education. Also, specialized teachers for the handicapped, in Italy then, were not yet invented! But the local governments could provide a psychologist, a speech therapist, a physical and occupational therapist and a social worker. And, they could provide a doctor! So, the social workers of the local communities had the task of forming teams called “Medical, Psychological and Rehabilitative Services”. This later became what we now know in the States, and in Italy too, “Child Developmental Clinics”.

The Social Worker in a nearby town heard about me, what and where I was doing it, and how satisfied everyone was with me. She called me and asked if I would be part of her team. She already had the other members on board but needed a physician. There were plenty of candidates but no one with nearly the minimal amount of experience needed. I accepted. I met all the team members and we got started. The Social Worker of another town found out about me from the first one and called me and I accepted. This went on with the next 3, which made a total of 5 Social Workers and 5 towns. I accepted all. I turned down the 6^th and all of them afterwards. I had no more time. With everything that I had and took on afterward, I was working from 8 in the morning Monday until noon on Saturday. Thank God for Sunday! I would get home usually at 8 in the evening every day. I was fully saturated, making money and so happy with what I was doing. All this went on for 10 years.

Chapter 3: Contracts Yes--Contracts No

However, all this initial success had its down side. Everything that I was doing depended on a yearly contract. Every year, I had to sweat it out waiting for the contracts to be renewed. All depended on money that the agencies had available. My original clinic and the various small town’s city budgets. True, this went on for 10 years but every year there was the fear that there was no more money to fund the teams. Every year, was I “Queen for a Day” and eventually back to where I started? This ambiguity took its toll in my marriage. Growing intolerance regarding my long hours, limited availability and questionable viability. I ask, isn’t limited availability for family stuff for a doctor universal? Should not women who marry physicians be prepared? I think not all are which is certainly true in my case and hopefully not true for any of you reading this. But, I was really only trying to survive in a situation that, from the beginning, seemed like the cards were stacked against me. My destiny, being American, was to stay American. My destiny was to practice in the States, in a group practice like all my peers, buy a nice house maybe even with a pool, drive a Mercedes or Caddy instead of a Fiat and have more patients than I could handle. You can imagine how I felt when I would occasionally go back to the States and visit with some of my physician friends. What elegant houses they had while I was in a rented apartment in Italy. I guess I rationalized thinking they didn’t have the local color I had. They didn’t have a beautiful piazza in the center of the city with colorful shops, local architecture that echoed hundreds of years of culture, churchbells ringing in the distance, people singing in the streets. Most of them didn’t have the mountains for skiing at only a 30-minute drive or the beach an hour away. They had beautiful homes but as far as daily living is concerned, I saw it was shopping centers and work, work and more work. Sure, I did have a lot of work, but not anything like what I saw my friends doing. But, they sure as hell had security which I did not. However, my ultimate conclusion was that I was very happy with the choice I made in spite of the possibility of crises regarding my contracts. I knew I was swimming against the current but I tried to be a strong swimmer.

After I was discharged from the Army in Frankfurt I was put automatically in the Army Reserve. This meant that if anything broke out somewhere in the world, I could be re-activated. At that time everything was pretty cool. Bin Laden was eating hamburgers at the White House. The only thing I knew about Afghanistan was the slim dogs that pretty blondes paraded around with. Iraq was somewhere East of the Mississippi. I was in the Reserves but it gave me only liability. However, being in the Reserves and doing Army stuff for another 12 years would give me some retirement income. I had already done 8 years of active duty and the magic number for retirement was 20. When I got to Vicenza, I went to the Army base to see if I could do my Army stuff there. It meant accumulating hours of service during the year; for me, hospital work instead Reserve meetings and a longer 2-week active duty status during summers. Just like they do in the States, Reserve meetings monthly and camp. But, I was not in the States and needed to be affiliated with some, any military facility to accumulate the hours and points needed for eventual retirement. Sort of agreeing to availability for active duty if needed in exchange for some retirement income. I spoke to the then Commander of the military hospital in Vicenza and requested to become attached so that I could continue on as a Reservist and also have an eventual benefit. He would not approve my request. I never knew why. I always had superior efficiency reports in the military. I was just recently out. I was willing to work in his clinic for no pay, just retirement points. I was willing to work in his ER which was a staffing problem then. All my attempts were futile and at that point I decided to resign from the Reserves. There was no logic to continue on with the possibility of being activated without any benefit. I said my final good-bye to the Army.

After I was in Vicenza for 3 years and working to the max, I got a call from the next in command at the Army base. He was a guy I met when I did my basic orientation training in Texas. He remembered me. He stayed in the Army and was transferred to Vicenza. He was in charge of outpatient care. He heard through the grapevine that I was in Vicenza. He questioned why they were sending patients for neurology evaluation to Germany and all that it cost when there was an American trained neurologist who also was in the Army and was right under their noses. There was also a change of Commander at that time. We met and he pleaded with me to accept a position as neurology consultant. It was only for one half-day a week since the volume was so small, but it would save them a lot of money and also enable me to make more since it would be on a much higher pay scale than what I got on the Italian side. I didn’t know what to do since I was already so busy, but I did accept and I became the Army consultant for not only Vicenza, but for all the bases in north Italy. I did this for the following more than 20 years! One half day a week. But, there was more. Hold on!

During 1980, the health system in Italy was changing radically. A national health system was being put info effect. All the private insurance companies were being dismantled and everyone was to be on a government system. Just like all the other developed countries in Europe; England, France, Germany, Spain, Benelux and Switzerland. Obama’s dream. Not America’s then, and not ever at the time of this writing. Only all the developed countries! Anyway, my Italian neurologist colleague who got me started initially had a brother who worked for the newly created system. He came to my house and brainwashed me into getting into it. He told me I could not get in as a neurologist since I did my training in the States. A contradiction since so many Italian specialists did a lot of their training in the States but they were always affiliated with an Italian university. I was not. There was no reciprocity. But, I could get into the system in general practice. The system was a sure thing for the future. I could adjust the patient load and hours that would fit into my already full schedule. I would have to get my own office. It was a tough decision for me. I didn’t want to do general practice, only neurology, but with the ambiguous situation regarding contract renewals, I chose to take the offer. I still continued on with my Italian child neurology clinics all over the place, my consultation at the Army base and now, general practice. I still don’t know where I got all the time to do everything but I did. I was really super-busy.

During 1985, what we feared would happen, happened. The national health system took over all the child neurology clinics I was working at and my contracts were cancelled. However, since I was still working at the Army base as neurology consultant, I had contact with my American colleagues there. One was a pediatrician who was put in charge of the newly created congressionally mandated Child Development Clinic. It was a carbon copy of what I was doing for the previous 10 years on the Italian side, only, this time in English. He was leaving and there was no replacement for him. He knew what experience I had in the field and convinced me to take his place when he left. Having just lost everything on the Italian side, I was only too happy to accept. My contract was approved immediately and I started as Chief of that service the summer of 1985 and continued on for the next 10 years. I was saved and more than doubled my income.

Afterward:

I think I’ll stop here in spite of the fact that my story is far from over. You can see that I got up to 1995 (1985 plus 10 years). It certainly does not stop there. Hard times and good times did follow. Professional and personal. I don’t want to impose on or monopolize your time. My book is rather lengthy and contains mostly non-medical stuff since it starts when I was about 4 years old living in Williamsburg, Brooklyn, in the Jewish ghetto. I am now 74 and still living in Vicenza Italy. I have been retired since 2007 and not liking it at all! The Italian Health System has mandatory retirement at age 70 and when you are out of the system there are slim pickings on the private side. I still would like to work. I know the immediate response of the reader would be why not come back to the States. The why not is another very long story. Thanks for sharing with me. Fred

Frederick A. Deutsch, MD

Vicenza, Italy

fredeu@goldnet.it

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March 13, 2011