An American ER Doctor in Switzerland

Dr. Sonja Knittel-Hliddal (@sonjamd)

Born and raised in California, Dr. Sonja Knittel-Hliddal (@sonjamd) spent a year (which turned into several) abroad in Switzerland. Her decision to study medicine was slow in the making. She eventually decided to attend medical school in Switzerland and spent most of her time working in the university hospital’s emergency department. She was enthralled by the knowledge, pace, and diversity she saw there.

Last Tuesday, @sonjamd answered questions from our users on Figure 1. Click here for the entire Q&A.

US vs. Switzerland

Several users asked about Dr. Knittel-Hliddal’s experience with medicine as practiced in Switzerland and how it differs from that of the US.

Is there a significant difference in the way the two countries teach medicine or is there a difference in the way the select people to study medicine? Which one do you believe is better?

There is a HUGE difference. Disclaimer: this is (obviously) my experience on the matter and generalized at that. The best of US higher ed requires engaged students; students who want to be there and learn. Students who participate in a class. It’s a consuming experience. Switzerland works with a MUCH more passive teaching method. Students rarely, if ever, engage in a lecture. They’re there but do not raise their hands or answer questions. When a professor asks something there was always a minute or two of embarrassed silence and then someone muttered an answer. That person was always labelled as a nerd. They weren’t related badly as a result, but it wasn’t something you wanted to do. Additionally, medical textbooks in German are exceedingly complex. I feel like the dogma is “the more complicated the subject matter, the more complex the text,” while my experience with english/american textbooks seem to try to keep the text simple while explaining a more complex subject. As far as application to med school is concerned: the US system is more competitive. In Switzerland you take an entrance exam and hope your score is good enough; no interviews or pre-med degrees. The US med school system has the gigantic drawback of being really, really expensive. If I could do it again, though, I’d study in the US in a heartbeat. Debt and all.

What are the most interesting cases you see on a regular basis in a Swiss ED [emergency department]? Safe to say there are fewer #Gunshot-wounds than in a North American ED?

There are almost no (I’ve never had one) gunshot wounds… Essentially all blunt force trauma. I’m not currently at a Level 1 trauma center (I worked at one during med school) so most of my cases are more internal med right now. Lately, we’ve seen what feels like a disproportionate amount of young first-time cancer diagnoses.

Enlarged abdomen case by @sonjamd
“18 y/o pt presented in the ER with enlarged abdomen (circumference had increased in the past 8 days). No fever, no chills, no sexual history.” Click to see the case by @sonjamd.

Please compare your experience working in a “socialized” medical system to the U.S. “capitalist” medical system.

I appreciate the quotation marks. My experience of the american “capitalist” medical system is limited — I completed one sub-i. What I can reflect on is the supposed socialized system that I do work in. While a medical system that, theoretically, insures all of its population sounds wonderful on paper, the reality is a little less ideal. One, it’s expensive. Really expensive.

Two, it’s coupled with a population that expects immediate treatment for everything and has little concept of what that does to the health system. Three, considering doctors get paid different fees depending on the insurance category of each patient, the system generates something a kin to a class system. The number of uninsured are less, absolutely (there are also a lot less people to insure), but more and more it is generating a system where health care and health care providers are employees of the patients. The biggest difference for me? In the US only what changes my course of tx [treatments] in the ED is done emergently and, all in all, it felt a little more pragmatic. We do a lot of “emergency” investigations (especially imaging) that in no way is an emergency.

Working in the ER

I found adjusting to constantly changing shifts difficult when I worked in emergency medicine. Do you have any tips on how best to adjust?

This is HUGE for me — and all my fellow residents. It’s a frequent source of discussion, too. I don’t have the magic system. All those tips about eating healthy and working out? Definitely help. I sometimes lack the motivation for both. Mine are smaller, I munch on nuts and carrots at work instead of eating a candy bar. I ride my bike to work and I don’t plan anything during a block of nights. The adjustment from night shifts is always the hardest for me. Drinking lots of water helps. And through it all, you have to be something who does like to work irregular hours and embrace them!

What are your thoughts on the use of opioid pain medications routinely in the emergency dept. In America we have a growing tendency to treat “pain” aggressively regardless of a formal diagnosis and it seems we are inadvertently creating a serious issue with addiction. I’ve heard that other countries are less likely to routinely prescribe high doses of opioids, being less consumer driven.

Excellent question! What’s lacking here, in my opinion, is a sensitivity/awareness for the potential problem opioids can cause. All the papers/blogs/medical professionals in the US I interact with are very aware of it. Here, not so much. And the majority of the patients receive opioids in the ED. I don’t know if I would say we routinely prescribe them in an out-patient setting, though.

Case by @sonjamd
“Pt came to the ER after being punched in the face.” Click to see the full case by @sonjamd.

Read the entire Figure 1 on 1 Q&A with @sonjamd.