“And they’ve always been bling masters. […]ancient Romans and Baroque priests alike knew how to lay on the glitz. […] People here are Catholic by ritual but pagan in essence, tying beauty, truth, and virtue together in a single knot. Americans, sotto sotto, consider not just sex but bodily beauty just a mite sinful”. Susan Levenstein
Susan Levenstein is an American expat who has an overflowing wealth of things to tell us. That she has spent the last forty years practicing medicine in Rome has given her a unique experience for an American trained doctor. Plainspoken and at the end of her career, she doesn’t shy away from handing out brickbats or revealing her affections. Her ‘Dottoressa, An America Doctor in Rome’ (Paul Dry Books, Philadelphia, 2019, 270 pp.), presents a incisive comparison between how the medical profession functions in the USA and in Italy. More than that, it reflects on the difference in character and outlook of the two peoples.
Levenstein has a feast to offer. Her anecdotes alone would fill a volume. Bursting with life, they are full of specific individuals, real people, characters like herself, in sketches that show her just as often the fall guy as the wise guy. A patient is a particular person for her, not always likeable but respected all the same. The detachment recommended to doctors often goes against her selective empathy, her likes and dislikes. She is ready to admit her naivety, her ignorance and the understanding that will only come to her after the event. Disarray can paralyse her, emergencies drive her to instinctive jumps into action whose recklessness play hell with the lethargy of the system.
“When I was an intern in the Morrisania [in the Bronx], an ambulance with red lights and blaring siren once brought in an emaciated old woman who wasn’t breathing. We did cardiac massage and within ten minutes had brought her heartbeat back, hung an intravenous line, intubated her, and sent her to the ICU [intensive care unit] on a respirator, when in walked her physician son, who’d called the ambulance. ‘What a blessing for my mother to finally die after so many months of suffering from cancer.’ Everybody started yelling at once: why hadn’t he ridden with her, why hadn’t he telephoned, why hadn’t he sent a note along, why had he called the damned ambulance in the first place? I walked out of the ER [emergency room] in a fugue state, my mind not knowing what my body was doing, took the elevator up to the ICU, turned off the respirator, waited until there were no more blips on the cardiac monitor, came back down and told the crowd they could stop arguing because she had died. I didn’t weigh the pros and cons of performing this act any more than I could have debated whether to run out of a burning building.”
A woman MD treating males can have surprises:
“An elderly and dignified religious brother once sat on my examination table in tense expectation with a blue cotton gown knotted around his neck. On feeling the first tap of my fingers on the back of his lungs, he ejaculated. For ten seconds as the stain spread over his gown, I stood paralysed in a jumble of shock, embarrassment, pity, guilt, and amusement, before mumbling something and taking flight. Some kind of sexual misconduct seemed to have taken place, but who was the abused and who was the abuser?”
The reader delights in these minute dramas, but at the same times wonders what they are leading to. That flow of wealth threatens to overwhelm him. Levenstein came to live in Italy in 1978 after she finished her rigorous medical training in New York. She was a qualified MD, had married a Roman engineer and fallen in love with Italy on tourist visits. But she would have to spend her first two years in Rome in a traumatic struggle with bureaucracy to get an Italian medical license. It was, she says, a lesson in pazienza, which she defines as “patience squared”. That gruelling time seems to have upset the organisation of her book. Expecting finally to plunge into her Roman doctoring, the reader must first read about the shady mysteries of the city’s real estate market and learn how her various offices had to change address seven times. At thirty-one she was unable to join the national health service whose beginners had to be under thirty-five and there was a five-year waiting list.
It was disappointing because Levenstein believed public trumped private service. She had been a “red diaper” baby. The expression goes back to a mythical time when the USA still had citizens not ashamed of being on the political Left. Her parents were “more or less” Jewish, her father a militant atheist. They took part in the ‘Ban the Bomb’ marches and Susan herself joined the ‘March on Washington’ in 1965 and in 1967 at Harvard lay down in front of Defense Secretary McNamara’s car in opposition to the war in Vietnam.
“…I was half a stranger in my own land and, at twenty-two, primed to embrace Italy in toto.”
She would have to practice privately in Rome, serving Italians but also expats like herself, tourists and international civil servants. One path through her labyrinthine reflections is to continue musing over her definitions. A Raccomandazione “has no pretence of being based on merit, and is never put into writing”. Lottizzazione is cake all around, the size of the piece depending on clout. Lo Stato, a busybody that wants to know when you move house. Mamma serves to stand in line for you at the post office. Sistemazione, “find your niche and nestle in”. Corruzione, “somebody’s nephew needs a job”. La legge,”so rigid it begs to be broken”. Amico, a friend not kept at arm’s length. Fare ante camera, sucking up. Pressappochismo, the hell with details. Nero, life under the counter. Commercialista, hired “to keep you from getting caught”. Pezzente, doesn’t show off by grabbing the restaurant bill.
However, it would be wrong to take Levenstein for one of those foreigners who loiter in Italy to exercise their sarcasm and add to their baggage of stereotypes. She often disagrees when Italians are too hard on their own ways and institutions. Her USA versus Italy game is a draw between two radically diverse teams.
To state the obvious, no country in 2024 is what it was in 1980. Levenstein admits that expatriation means “Your native land keeps moving forward without you”. Visiting America recently she finds that not only medical practice but everyday assumptions and even the vocabulary have so changed she can no longer make the same comparisons she did with Italians and Rome. She arrived forty-five years ago to find that future Italian doctors could pass through years of medical training without having direct contact with a single patient. One student summed it up saying they “get stuffed with facts for six years but never learn how to hold a scalpel”. Their study dealt only with theory and books. This shocked her because her US medical education had called for cutting into a cadaver the first year and three years of residency as an intern afterward meant she was actually to some extent doctoring patients.
Now Levenstein does tell us that by 2008 Italy did manage to conform to European norms
and put students into hospitals for bedside experience. But the example does point to the problem an expat has in keeping up with change. Pushing her conviction that Italian studies are too theory-prone, she reports one parent complaining that her child spent all of her physical education period sitting at her desk. But by chance the present writer overhead a conversation in 2024 in which an Italian mother’s grievance was that a teacher failed to assign homework because too much of the school day had been spent exercising in the open air.
One clear superiority of the Italian system is that the government negotiates the prices of medications with pharmaceutical companies. This eliminates the price-gouging Americans are subject to. Levenstein notes the spectacular difference in drug prices in the two countries. For example, an injection of corticotropin to stimulate adrenal glands will cost $16 dollars in Italy and $7,000 in the US. One CEO of a ‘big Pharma’ outfit even justified this sort of thing:
“It is a moral requirement to make money when you can.”
The tendency to make something like a religion of raw capitalism has a decided Protestant flavour and includes body-shame. Levenstein traces it in the few words Americans have for genitalia. While an Italian mother might refer to her baby boy’s “cute pisanello”, or pisello, or pisellino, among other terms. Her American equivalent would say “his thingy”. About her girl baby, she would be speechless, whereas the Italian mother would have have a host of fond terms, including patatina, topa, gnocco, papera, fichetta,
The pros and cons of Levenstein leave us in two minds:
“Health heaven: the funding, hospitals, and doctors’ education are American, the lifestyle and access to care Italian. Health hell: Italian budgets, medical training, and ICUs [intensive care units]; American pricing, coverage, Big Macks, drunk driving, weapon-mania, couch potatodom, and street corner opiates”.
The draw between the two ways of medicine and of life nevertheless leans toward Italy. After all, it is the place where Levenstein freely chose to spend most of her life. An Italian translation of ‘Dottoressa’ is being prepared.
The reader closes the book amply entertained, clued in to what doctors are up to, and seeing his own expat experience in a new light.