September 17, 2004
Sociology of Contemporary Rome
A Comparison of Physicians in Italy and America
Nearly every society currently in existence has its equivalent of a physician. While medicine men of small tribes work their magic in huts and modern physicians practice in state of the art hospitals, all doctors work with the intention of assisting the ailing. However, each doctor must function within confines as dictated by the society in which he or she lives; medicine men must learn the chants and herbal remedies developed over generations while modern doctors learn to perform surgeries as developed through numerous applications of scientific theory. It thus comes as no surprise that despite the numerous similarities between how American and Italian physicians diagnose and treat patients, many differences in their roles in society still remain. This paper aims to compare the medical doctor profession in America and Italy, and to suggest some possible reasons for any differences.
One of the greatest similarities between physicians in Italy and the United States are the motivations for pursuing the profession. While there is minimal literature on the subject due to the numerous possible responses, the similarities in the appeal for becoming a doctor become evident when speaking with people in the field. Dr. Riccardo Ciofani, a family practitioner at Salvatore Mundi International Hospital, described his interest in becoming a physician as starting at a very young age and beginning with a genuine interest in science and human anatomy. This curiosity in the field of medicine then grew as he discovered a desire to work with others. I found this response very surprising because it perfectly captured my own reasons for an interest in the profession. This similarity between two individuals from diverse backgrounds suggests a fundamental purpose for the profession that transcends cultural differences.
Education is the first major step in the path towards becoming a doctor. Medical education differs greatly between the United States and Italy in the admissions process and the system of education. American medical schools focus on producing a limited number of graduates who have a broader base of knowledge while Italian medical schools produce an unlimited number of graduates who have more vocational training.
In the United States, admissions to medical school is an intensive and lengthy process requiring both primary and secondary applications, as well as an interview. For example, refer to the informational website for the University of Washington School of Medicine Admissions Office. It elucidates that admissions is granted based on several factors including: the applicant’s grade point average in undergraduate education, performance on the Medical College Admissions Test (MCAT), involvement in extracurricular activities, application essays, and interview responses (MD Admissions Program Online). In 2002, there were 33,625 applicants to American medical schools, of which only 17,592 were accepted; this yields an applicant to accepted applicant ratio of nearly 2:1 (Barzansky and Etzel 1192). The selective admissions process of U.S. medical schools thus promotes a competitive environment that theoretically results in only highly qualified students being allowed to pursue a medical career; it also limits the total number of physicians, thus producing only as many medical graduates as the job market requires.
The rigorousness of the admissions process for American medical schools is in sharp contrast to the leniency of the Italian admissions process. Until the end of the 1960s, the only requirement for entrance to Italian medical schools was the completion of classical secondary studies; by the 1990s, admission was unrestricted- irrespective of any high school degree obtained (Simini, Italy supersaturated 1552). This approach promotes medical education as a vocational program rather than a continuation of higher education since students transition directly from high school to medical school without acquiring a general knowledge foundation in the form of an undergraduate degree. As a result of the lack of requirements for entrance into this system, medical schools were awarding 9,000 medical degrees annually by 1995 (Simini, Italy supersaturated 1552). In an attempt to curb the number of students getting into medical schools, Italian universities began requiring students pass an admissions test. Although this initially helped decrease the admissions to 7,000 students per year by 1997, it has since become unsuccessful because applicants who failed the test sought legal redress by appealing to regional civil courts (Simini, How little 1615). These courts have consistently ruled in favor of the students, citing the university’s lack of authority to decide “arbitrarily” how many students to enroll and entrusting that authority to currently un-established national plans (Simini, Italy’s unequal doctors 783). As a result, the citizen’s right to access to higher education triumphs, regardless of his or her personal abilities. This system results in crowding in the classrooms and consequently relies on grueling examinations as a selection process.
Once the medical school admissions process has been considered, it becomes apparent that Italy and America offer two completely opposite approaches to a medical education. The US medical education system allows students more options in terms of when to commit to a medical career, however it also takes longer to complete. Students are allowed the freedom to pursue any undergraduate major, provided they complete the general science requirements for medical school (Hwang 860). This system promotes undergraduate education for personal enrichment; medical school serves to continue education. After acceptance to a particular medical school, students must commit at least another seven years to completing the necessary schooling and training. In medical school, students spend two years in classroom and laboratory study of health sciences and then another two years working with patients under the supervision of licensed doctors; this sums to a total of four years to gain a medical degree (Pace 1198). Next, through a national matching service, recent medical graduates are assigned to a professional training program where they work for three to six years until they earn a medical license (Hwang 860). Doctors by this time have the option to complete a fellowship for up to two additional years, which allows them to specialize in a particular field and to receive board certification in a subspecialty (Pace 1198). Thus, the American educational system allows a greater degree of freedom for students to choose when to commit to a medical career. However, once a commitment is made, it takes longer to complete the necessary training before new graduates can practice medicine.
In contrast, the Italian medical system requires a commitment from students earlier in their post-secondary education, and earlier specialization allows students to finish training slightly sooner. In Italy, medical school follows directly after high school, although completion of secondary school is not mandatory (Simini, Italy supersaturated 1552). One example of typical Italian medical education occurs at Universita degli Studi di Cagliari, where students mainly take lecture courses during the six years of medical school and there is minimal, if any, required clinical training (Facolta di Medicina e Chirugia di Cagliari Online). After graduation from medical school, students generally take another six months to one full year in preparation for the licensing exam; upon passing the licensing exam, doctors are free to practice medicine (Ciofani). From here, physicians have the option to continue training to specialize, or to find a job. Thus, within seven years, Italian physicians complete all necessary preparation to practice medicine, but must commit to the career right after high school.
Once able to practice, Italian and American physicians share a similar status in society, but differ in the structure in which they must work. Italian doctors must work within the confines of the socialized National Healthcare System. American doctors must practice medicine as dictated by insurance companies.
The physician’s status in society appears to be consistent across cultural differences. In America, doctors have a high occupational prestige level of 86.5 points out of a total 100 (Hauser and Warren 107). This high ranking can most likely be attributed to the difficulty in completing the education necessary to practice in the United States and the high demand for physicians. In Italy, based on my experience in speaking with Italians and with Dr. Ciofani, it appears that doctors share a similarly high prestige level. The reason for the high prestige level in Italian society cannot necessarily be explained by the same reasons as the United States because data regarding the profession appears contrary to the qualities that distinguish a profession as prestigious. For example, the ease with which a medical education can be attained suggests that the profession should not be regarded so highly. A possible explanation for this phenomenon is that it is a residual sentiment based on the high status in society that doctors have historically held. Nevertheless, doctors in America and Italy share a similar respected status in society that is perhaps due to the significance of their role serving the general population’s health needs.
The two distinct healthcare systems in which physicians of Italy and America must work are responsible for most of the differences between how professionals from each country practice. In America, doctors earn their income primarily based on the number of patients they see. Doctors them submit itemized bills to either the patient or their insurance company for compensation for their services. The average income of an American family practice physician was $164,000 in 1997 (Spitz). Physicians can then increase their incomes by increasing the number of patients they see in a given workday. This method of payment contrasts to the system in Italy. Italian doctors are hired under contracts by the socialized National Health Service and are thus paid by the government as per their contract, rather than based off of the number of patients they see; contracts for a general practitioner pay on average €800 per month because most of them are only for part-time work. To supplement their income, many Italian physicians begin seeing private patients, who pay for their own visits; this allows Italian doctors to earn up to €2,000 monthly (Ciofani). This salary roughly sums to €9,600 annually and, even when supplemented to reach approximately €24,000 annually, is significantly less than that of American doctors. The reason for the disparity is the fact that Italian doctors’ salaries are dictated by the Italian National Health Service, which spends only 8% of Italy’s gross national product on healthcare (Apolone and Lattuada 378). Since there is a monopoly on the employment of physicians in Italy by the National Health Service, they are able to maintain such low salaries.
Another disparity between American and Italian doctors is the opportunities available to physicians who have completed their medical education. In both countries, most physicians primarily focus on seeing patients. Physicians in both countries also have the option of also performing research or teaching. However, the difference is the ease with which physicians in each country can pursue non-traditional career paths. In the United States, medical doctors have equal access to research grants as any other researcher; thus there are numerous opportunities for physicians in research (Laster 302). However, many Italian physicians, such as Dr. Ciofani, do not feel comfortable pursuing a career in the research sector because of the limited availability of jobs in research for physicians. Thus, Italian physicians have less freedom in choosing to pursue other career options.
One note of particular importance regarding doctors in the Italian healthcare system that is worth discussing is the excess of physicians in the country. Over the past thirty years, the number of registered physicians in Italy has quadrupled, paralleling little increase in overall population size (Simini, Italy supersaturated 1552). By 1996, the number of physicians registered in Italy numbered over 350,000; of these 70,000 were unemployed and many more were underemployed (Remuzzi 174). Estimates by the previous Italian Health Minister, Elio Guzzanti, calculate an excess of 100,000 doctors (Keates 390). In fact, nearly three quarters of the 34,000 practicing dentists were previously medical doctors (Simini, Italy supersaturated 1552). The cause for this occurrence appears to be the low barriers to a medical education. In fact, when the Italian medical association, Federazione Nazionale degli Ordini dei Medici, Chirurghi e degli Odontoiatri (FNOMCeO), recognized the oversupply of doctors, their first step to counter the problem was to appeal to the government to limit medical school admissions to levels equal with the nation’s capacity to accommodate newly graduated physicians (Simini, Italy saturated 1552). As previously discussed, subsequent efforts to decrease admissions have not been successful. As a result, the government has been searching for other ways to decrease the number of registered physicians in Italy. One of the ways the government has attempted to do so is by preventing physicians who did not receive their medical degrees in Italy, or from other countries who share reciprocal validity of medical degree agreements with Italy, from practicing in the country. This attitude on the part of the government has led to statistics concluding that there are far more Italian doctors practicing abroad than foreign doctors practicing in Italy (Simini, Foreign doctors 811).
These findings are in direct contrast to the situation in America where unemployment amongst doctors is virtually unheard of. Currently, there are over 700,000 practicing physicians in the United States, and this number is still not sufficient for the healthcare needs of the country (Hwang 860). In fact, a shortage of general practitioners has developed in the United States over the past decade and if it continues in the same pattern, the national physician shortage will peak in 2020 when there will be an estimated deficit of 200,000 doctors (Glabman 6). The main cause for this shortage in America seems to be the difficulties that physicians now encounter when they practice medicine.
It is the undersupply of doctors in America and oversupply in Italy that underlies the policies of the governments of each country towards foreign doctors. In America, international medical graduates, or physicians who completed medical school in a foreign country, are readily welcomed into the country. In fact, international medical graduates account for nearly 26% of first-year residents in training in hospitals (Setness 9). Most United States medical licensing procedures simply require that these foreign-educated physicians have either U.S. citizenship or a green card, and have completed residency training in the States (Hwang 860). The willingness of the United States in accepting these professional immigrants can most likely be attributed to the shortage of physicians. This fairly open policy of America differs from the restrictive policy of Italy, where a bill was approved preventing doctors from any other country from practicing in Italy unless they obtained their diploma from an Italian university or received their diploma from a foreign country which grants equal right to Italian doctors to practice in that country (British Medical Journal Online). The hesitance of the Italian government to allow international medical graduates is perhaps due primarily to a reluctance to allow immigrants an opportunity to claim jobs that are well sought after by Italian physicians.
The common denominator concerning the medical professions in America and Italy deals with the problems that arise between physicians and the established system that controls how they practice. In the American healthcare system, physicians are increasingly feeling pressured by the over-regulation and managed care put forth by insurance companies, as well as the rapidly increasing malpractice lawsuit rate (Glabman 8). A survey of United States physicians aged 50 and older found that nearly half of the people surveyed planned on retiring within three years because of the pressures more recently associated with the profession. According to Joseph Hawkins, chief executive officer of Merritt, Hawkins & Associates, the health-care staffing firm that conducted the survey, “doctors no longer enjoy the control and autonomy they once did” (Spitz). American doctors fortunately earn enough money to have the option of reducing the number of patients they see or retiring early in an attempt to avoid the problems that plague their field.
These options cannot be afforded by Italian physicians who must deal with similar bureaucratic hurdles. Dr. Ciofani explained that in his opinion, the biggest problem with the Italian healthcare system is its lack of funding to support both patients and doctors. It is this funding issue that is responsible for the low physician salaries in Italy. This lack of financial support is evident in the fact that doctors in specialist training are both unpaid and uninsured (Simini, Italian Medical Association 1829). Due to the widespread dissent regarding the healthcare system, Italian doctors join unions to protest their working conditions (Simini, Italian Medical Association 1829). In the case of the specialists in training, frustration could only be expressed in a nationwide strike that paralyzed the entire division of university based healthcare; a few doctors went on hunger strike while their fellow dissident doctors gave them infusions, some began offering medical consultations on the street, and other doctors went out in their white lab coats to clean the windshields of cars stopped at traffic lights (Simini, Italian Medical Association 1829). Despite the differences between how physicians in the United States and Italy deal with problems in their field, it is evident that both face major issues when dealing with their respective healthcare systems.
When examining the differences between physicians in America and Italy, it becomes evident that despite sharing a title, medical doctors in each country function under very different constraints. The main issue that arises is the undersupply of physicians in America contrasted with the oversupply in Italy. These problems with each society are caused by the policies that govern how the profession is regulated. For example, in America the competitive environment for applicants in the admissions process to medical school greatly limits the number of individuals who have access to a medical education. When practicing medicine in the United States, physicians are becoming more frustrated with the new restrictions that are being imposed upon their profession by insurance companies. This is consequently leading many healthcare professions to leave the field through early retirement, partly because they can afford to do so. Thus, combined with the inability of medical schools to produce enough graduates to match the number of older physicians leaving, there are several factors leading to the undersupply of doctors in America. This promotes policy allowing international medical graduates into the country to fill the gaps.
In Italy, the medical education system does not limit the number of graduates in any way, thus serving as the main source for the excess of physicians in the country. The lack of opportunities for doctors in other avenues outside of practicing medicine, such as in research or teaching, also contributes to the high unemployment levels amongst Italian physicians. In an attempt to preserve the number of job openings, this in turn leads to strict policies regulating who can practice within the country.
America and Italy appear to suffer from problems on two opposite ends of a spectrum; Italy has too many doctors and the United States has too few. Fortunately, each country is in the process of taking steps to remedy these problems. Despite the differences, American and Italian doctors share several similarities such as motivations for pursuing the profession, status in society, and problems associated with working in the healthcare system. Thus, physicians in the United States and Italy are more alike than different and are jointly contributing to the healthcare services that all physicians provide.
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