Academic teaching & research

Salvatore's letter

What young people tell us. The experience of a doctor in training abroad

Salvatore's letter, a "young doctor" that at the end of the second year of specialization went outside Europe,  delivers its experience and tells us how the training of our specialists is working, as related by the "emigrants" of the profession, at levels below the average.

The debate about medical training in Italy, on the destiny of the young doctors, the scarcity of their training, and on the abysmal distance between European and our standards, with the the worse previsions confirmed by parliamentary amendments contained in PA reform on specializations, has reached a crucial point. While the landscape of the healthcare is definitely changing, since public hospitals are reducing in number and less and less prestigious, our specialist training continues to be, even in the experience of "the emigrants", as one of them tells us here, sorrowfully to substandard levels. Who will, in this situation, rebuild on the current ruins, and most importantly, if not now, when everything is speed, when?
Dear Prof,
I send you a reflection through which I try to tell my experience of Italian physician in training abroad with the purpose of focusing on the professional component and telling one of the many efforts and sacrifices that take place in favor of a country and a profession for which we are deeply in love. I want to point out that what is written in this script doesn't absolutely represent a controversy with Italy, the country that I love, and I thank for having made me how I am and that gave me the possibility to chase my dreams.
A day of my second year of specialization, my Chairman, one of the few animated by enthusiasm for their profession, has accepted my request to deepen my knowledge in the field of Obstetrics. After the appropriate bureaucracies and an interview structured in two days that I had to sustain at the host Institution, I asked for and got a two-year fellowship in one of the most important Institutions of the world for Obstetrics, an advanced-level centre with its nearly 16,000 deliveries per year for a population of almost one million people, which refer all to the same institution.
 From July 2013 I am working at Soroka University Medical Center in Beer Sheva (Israel), and I am involved within the international programme run by Prof. Offer Erez, my mentor ever since. I left Italy because I knew it was time for me to go where I could learn things in my country I wouldn't have been able to learn,  for several reasons. The first, and as far as I'm concerned the most important, is linked to the scarcity of the numbers reached by training specialists within University Institutions distributed across the country. From one day to the next I found myself catapulted into a completely different reality from the one in which I was used to live. A place of which I did not share  the language, the customs and traditions, the religion and where even taking a bus could be a problem since Italian and English have little in common with Hebrew. But when I started working at the hospital, every difference between me and this country seemed disappear.
I found a perfectly organized world where everybody knows exactly what needs to be done, and how to do it. A world in which nobody  claims knowledge a priori but provides all the tools in order to achieve the autonomy of action and learning, a world in which you are educated to understand your mistakes and learn from them with the understanding and serenity that haven't been committed because of negligence. I joined a fantastic team that welcomed me with great enthusiasm after they tested my genuine desire to give my contribution working hard, so I started my experience based on clinical work and research.
From a clinical point of view I am involved in the management of high-risk pregnancy, obstetric ultrasound, and in the management of physiological and pathological labor and delivery. I will never forget the day they put me for the first time the scalpel in my hand and told me "Please, now it's your turn". A case of severe IUGR with estimated fetal weight 1, 700 g at 37 weeks in a patient of about 40 years old and first pregnancy, after several attempts of assisted reproduction. Not exactly a case that in Italy all residents would be allowed to operate.
 Not for sure as first operation in the career. At the same way I will never forget the question at the end of the operation: "Congratulations, but how many Caesarean sections have you performed as leading surgeon?" exactly like the colleagues's face when I told him that for me that was the first. And I must thank Italy for these compliments because, if on one side it is true that I have never been put the scalpel in my hand, it is also true that Italy gave me the knowledge in order to know exactly what to do at the right moment, and gave me the opportunity to show how consistent is the preparation that our system provides. From that first operation, I run almost every type of caesarean section in the presence of all types of obstetrical complication (the post seven Caesarean sections and placental accretism I still watch as a spectator, but give me some time and maybe the perspective from which I look at things could even change!).
I run every day, always under the supervision of a tutor (usually a senior resident or a consultant), each type of pathology or obstetric emergency, and don't believe that in Israel, even in a so advanced country, everyone has the answer to everything at all times. There are many cases in which everyone runs to a different computer to search for information on a topic to which you must respond as soon as possible, meeting altogether again one or two minutes later with the responses to the problem. Responses from which the debate leading to the definition of the management of the case starts. Every morning from Sunday to Thursday (in Israel the weekend includes Friday and Saturday, during which I often meet the professor who is responsible for my program, to work in the drafting of papers of investigation), we meet in the conference room of the Department where the cases of the previous day or weekend are discussed.
Twice a week the day starts at 7.30 for a lesson that is held by a resident, a consultant or an international visitor to an audience represented by the Chairmen of the two departments, consultants, residents and medical students. Depending on the topic, sometimes neonatologists, surgeons, or any other type of specialists involved. I've been included in this, and believe me, giving a talk to a group of 40 people with some who gave the name to the obstetric pathologies with which we face each day, is one thing that scares. But it is a challenge that has to be part of the baggage of a young scientista title that the resident in Obstetrics and Gynecology needs to  be attributed.
The second part of my fellowship begins after 3.30 pm, when the workday ends, and is represented by the study protocols in which I am involved and the production of scientific papers, always tutorized by people with great experience in clinical research but also in basic science. I presented the results of my work, performed in the group to which I belong, to the most important world conventions. In less than a year I've been in three continents, something I would have never imagined in my entire life.
 And each time is an opportunity to create new relationships, see new places, establish international connections that can blossom in collaborations and personal enrichment, as well as important material for all the scientific world. Our research group works on different topics, to which several subgroups of people are assigned, and once a month, at 7 in the morning, before the workday begins, we meet to do a check of the progress of the different protocols. I shook hands with people I read the name only on the most prestigious scientific journals, and I discovered the extraordinary humility and preparation. Impress you when the world's greatest expert on placenta asks you to call him by name and discusses with you even the most worthless and unenforceable idea that comes out of your mouth without making you feel a complete incompetent in this area. And even asks you to keep in touch to share other points of view in the future. And believe me, these people really respond when you write them an email.
 For the future I have several projects, but there is one that I believe is absolutely a priority: getting back to my country because I am strongly convinced it only needs new lymph and enthusiasm to reboot. This attitude is, in my opinion, the only useful key to clear the road from the redundant criticism but unfortunately often sadly shareable that leads many, in their freedom to choose the easiest way, represented by pitiless court that is made us by all the countries of the world and is difficult not to consider.
I don't feel acceptable the idea, that I personally do not even take into consideration, that the country that gave birth to the greatest artists and scientists of history, now wants to give others an army of young minds, after paying handsomely for their training, and I will continue to do my best to convey my commitment towards change and personal and environmental evolution, to anyone who is animated by passion for our work and is ready to fight until  dreams become reality.

Salvatore Andrea Mastrolia Resident at the IV year, school of Obstetrics and Gynecology, 2nd Department of Obstetrics and Gynecology, Policlinico of Bari".
Salvatore, a "young doctor" already so responsible, that at the end of the second year of specialization in obstetrics and Gynecology went outside Europe, in a country historically not so quiet, with a precise mission: to bring home the Obstetrics Science that during the decades we missed out on the street, along with the underestimation of the key importance of our work, gaining in return only a sad record: the highest number of cesarean section in the world.

Sandra Morano
Research Professor at Università degli Studi di Genova