Impressions: An American in Lucerne

As I get ready to open a new chapter in my life, I share an article I wrote in 2016 and was published in German in a Swiss journal.

There is a sense of excitement in the opening of new doors but also a sense of angst as doors close. In as much as moving to this country meant leaving behind a mountain of good things in Boston - a dream life, a dream job - and upon arriving in this new land, Switzerland, I felt a deep sense of loss and mourning, I remember that 10 years ago I made this change with apprehension accepting my then wife's life-long desire to move to her native country. Nearly a decade elapsed since then. Many new valuable experiences. A very sad chapter in between. Then, new important lessons, some of which I offer here. The translation of the article I wrote begins below:

VSAO Journal 6 16 Seiten 30 - 31 Ein Amerikaner In Luzern.pdf

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Recently, while driving on the A14, looking at Mount Pilatus ahead and the Rigi behind the Zugersee, I found myself thinking about my former life as an academic doctor in the USA, and I asked myself if it is merely human to compare and contrast life experiences. So it is.

When did this journey start? Years ago, while busily writing papers and building a career as an academic neurologist in the USA, I caught my Swiss wife Patricia reminding me how wonderful it would be if we eventually moved to Switzerland with our four children. During years I resisted her plea. My career was emerging successfully and I had a leading position in one of foremost hospitals in the USA. Massachusetts General Hospital (MGH), Harvard Medical School's chief training hospital, is one of the most exciting medical centers in the world. Harvard Medical School students busily run from conference to conference, physicians are curious and passionate; the research is outstanding. The menu of daily lectures is staggering. That is, one goes to hear world-class lectures between patient visits. It is simply thrilling. I could not have been happier working at MGH. However my wife was not quite happy in the USA as she felt Switzerland could offer a better quality of life to our family and that the working conditions for physicians were better in Switzerland. It took her years of persuasion; many tearful moments. Eventually I myself got to shed a tear when I left all of my colleagues and research behind in Boston. I decided to trust my wife's instincts. She even assured me I could learn German quickly and I could easily work in Luzern using the French I already spoke fluently. My colleagues at MGH felt I was a bit crazy to leave them and "move to tiny Switzerland". I had hesitations but as they say, "cherchez la femme", one has to follow one's wife. All of her persevering over the years managed to sway me.

The beginning was quite rough. I could imagine my secretary pulling her hair when I made a dictation, a medical report or a letter. Learning German in one's fifth decade is not for the faint of heart. But four years later I can say, have come to appreciate many valuable and cherished aspects of life in a Swiss hospital.

American hospitals have heterogeneous staff. It is normal to hear all sorts of foreign languages in the hallways of US teaching hospitals. Faces of all colors and creeds, first generations Americans, intermixed with second-generation Indians, Europeans, black Americans, and so on. Swiss hospitals also have ethnic heterogeneity but the amplitude of possibilities is reduced to central European faces. Heterogeneity here means German vs. Swiss, East vs. West and so on. I find it entertaining to have discussions with colleagues about the "vast" differences in mentality between doctors from Graubunden and those from Wallis. Colleagues from Ticino are seen as unusual. Initially, given my limited German knowledge I was seen as an "exotic breed", a variety of doctor not previously seen, a museum piece. Not a day would go by without someone asking; "what are you actually doing here? Why did you come to Switzerland?" suggesting I had been infected by a parasite which took over my brain.

One of the most striking impressions upon entering a major Swiss hospital is that one sees far fewer "suits". "Suits" is the rather unpleasant term American doctors use for members of hospital administration, that is, all the personnel which are involved in the running of a hospital who are not trained in medicine or nursing. Hospital administrators wear suits with tie, and are decidedly visible. An explosion of administrative positions in large university hospitals in the USA has alas occurred. The rise in these positions has since long far outweighed the increase in physician and nursing positions. This includes insurance representatives, DRG consultants, length-of-stay- specialists, executives, and of course many department administrators, sub-administrators and sub-administrator assistants, also in suits. Adding to this "suit" soup, the fact that in many large US hospitals there is no actual mandatory white coat policy for physicians, one can easily imagine why patients feel often confused and disappointed.

In Switzerland doctors exercise greater control over their own lives. I see this as particularly important and positive. An admirable example of doctors taking control of their destinies is the Augenklinik Luzern. Under the impressive leadership of Prof Michael Thiel, self-funded, doctor-directed, doctor-designed, patient-centered, this exceptional eye clinic functions without much bureaucratic control or administrative load. It is quite remarkable, indeed! I am not sure this would be possible in the USA, where doctors are confronted with loss of autonomy on a daily basis. It is not a secret that in the USA many doctors are unhappy and thus leaving medicine. There is a sense that hospital administration has become onerous, that insurance reimbursement is abysmal, that the new Obamacare plan is a rip-off. American doctors talk about this continuously. There is no good reason I can think of, administrators and the government alone should be the ones making the big decisions which permanently affect doctors. This might be the reason physicians' morale in Switzerland is often happier than in America. A small detail…doctors in Switzerland take more vacation and the salaries are typically higher.

Four years later Switzerland has become my new home. There are many things I truly enjoy about Swiss hospitals, not to mention life in Switzerland. Although the financial "bottom line" is as important here as it is in the USA, although recurrent DRG themes, length of stay, flat-rate payments and worries about falling reimbursement have filled the eyes and ears of Swiss doctors and administrators, there is a gentler and less frantic way of living here which has solidly won over me.

The clinical conferences at LUKS, my hospital, the science symposia at neighboring university hospitals, the lectures and continuing educations activities are no doubt world class. This might have to do with globalization; with the fact the world is smaller today than ever before - medicine is no exception. Needless to say that many of the medical lectures in Switzerland are delivered in English, is music to my ears.

After finally bringing my German knowledge to the point I can dictate letters, speak to patients, to colleagues, and give lectures, I concluded that by virtue of the fact that the Swiss are so gifted in language and have no problem switching from one language to another, giving a lecture in English is typically not only welcome, it might go unnoticed.

Swiss doctors are more practical than American doctors. They order blood tests which clinical make sense. In US hospitals, and probably as a result of electronic medical records order entry, doctors tend to order by "panel (wholesale) clicking". Click this panel, click that block…it is easy to click away on the computer screen… One does not just send a single realistic blood test but all the tests which appear in the category. After all, someone else is paying for it. No wonder the cost of medicine in the USA is astronomical. One click and you've ordered all of the paraneoplastic antibodies…all of the coagulation studies, DNA tests for 20 rare diseases, including tests for diseases which are vanishingly rare. In Switzerland one is more careful and will ask for permission to the health insurance company (KoGu Gesuch) to request an expensive blood test. I am fully in favor of this approach. Furthermore, very expensive new technologies are not immediately embraced here without careful consideration to their utility and benefit to the patients. Older but clinically established test modalities still play an important role in Swiss hospitals. Ultrasound is an example of this phenomenon. In the US, ultrasound for vascular disease has been almost completely replaced by CT- and MR-Angiography, far more expensive but not proven to be associated with better clinical outcomes.

A word about uniforms: I can remember the first time I saw a sign in the dressing room wall that read: "Kleider machen Leute". Initially I thought this was medieval thinking. A few years into working in a Swiss hospital, I realize this approach makes sense. Clarity of roles helps patients feel more secure about their hospital experience.

And speaking about patients, the one aspect of Swiss medicine which has impressed me most is the resilience and independence of the older Swiss population. In the USA it is common to send a patient to a nursing home (Pflegeheim) after a stroke. It is an automatic decision which is sometime too easily made by hospitals, with acquiescence of the family. Loss of patient autonomy seems to be welcomed by all, oftentimes, without appropriate deference to patient preference. Getting older in the US sometimes means entering anonymity. After all, nursing homes are a trillion dollar industry in the USA. I admire the fact that elderly Swiss patients will insist on going home after having had a stroke or heart attack. It might mean they will crawl to the bathroom, or even die. But this will take place at home. Their home, the house of their ancestors. There is something poetic and praiseworthy about this way of life.

Also, it doesn't hurt that one can have lunch seated, overlooking the Alps and eating out of porcelain dishes instead of paper plates. In Boston I sometimes ate fatty food in an elevator going from patient to patient or in a conference room while listening to a lecture, while fighting sleeplessness, and watching Indian food dripping on my white coat. Separating food from learning or professional discussions is healthy.

Welcome to my new home, my new medical house.

The lake of Lucern and its crisscrossing steamships. A daily routine to work included these views

Bicycling in the rolling hills of Switzerland - a paradise