Dr Alper is a practicing internist in Burlingame, Calif, and a Robert Wesson Fellow in Scientific Philosophy and Public Policy, Hoover Institution, Stanford University, Palo Alto, Calif.
Philip R. Alper, MD
Illness in the family is something that eventually confronts all physicians. Perhaps as a saving grace, unwelcome events can extend our knowledge in ways that may surprise us. So when my wife and I embarked on a nearly 3-week trip, we hoped that she would be distracted from the misery of neuropathic pain.
Wolfgang Amadeus Mozart was born 250 years ago, and it was this anniversary that inspired B?r?nice to want to literally follow in his footsteps across Southern Germany and Austria. Beyond the value of medication, she had found her profound love of music to be both a comfort and even an analgesic. For B?r?nice, Mozart and medicine were intertwined.
I must admit that this trip, which was intended to be "for her," also put me under the spell of Mozart's life and music, but with an additional agenda to satisfy the "doctor" in me. In addition to visiting places associated with Mozart, I arranged to look into the state of primary care practice in the Austrian and German semisocialized health systems. My summary conclusion: Germany has big problems; Austria is better off. Only 42% of German doctors are generalists; the corresponding figure for Austria is 62%. Germany also has more doctors per capita.
Medicine gets squeezed when the economy is in trouble, as it is in Germany. Primary care physicians, who work in a regulated fee-for-service climate that is administered by 200 insurance carriers, are hardest hit. They are now paid only a portion of the fees they are due and must wait until after the end of the year to learn how much of the rest will be forthcoming. Each insurer discounts differently, depending on its overall underwriting experience and budget maximums. Primary care physician income has dropped by up to 50% in the past 3 years.
Unlike living with American-style HMO withholdings, German primary care doctors cannot manage by just practicing and prescribing more efficiently. The more services they provide, and the higher the value of the prescriptions they write, no matter how necessary they are, the less they can expect to be paid per unit of care. In effect, they must choose between their paychecks, workloads, and their own patients' welfare.
Nothing like this is visible in the housing, clothing, condition of the highways, or the impeccable upkeep of lovely old buildings amidst spectacular scenery-or in the demeanor of the people in either country-all of which proclaim cleanliness, orderliness, and good health. Nor, incidentally, could we make any connection with, or better understand, the events surrounding World War II, even after talking with many Germans and Austrians and visiting Berchtesgaden and the Obersalzburg, Hitler's and the Nazi party's now nearly dismantled Alpine retreat.
We stayed near Berchtesgaden in the spa town of Bad Reichenall, at the very pleasant traditional Steigenberger Hotel Axelmannstein. A 20-minute evening drive into Salzburg (the Austrian border is entirely open) took us to our first Mozart concert at the Mozarteum auditorium. We had heard the Salzburg Chamber Soloists play before, at Stanford, Calif, but this time was different. Two sopranos singing Mozart operatic arias supplemented the orchestra's chamber pieces. With a little imagination, the white and gilt baroque room merged with the music to make the centuries disappear. B?r?nice was enthralled. We both commented on how much better she was faring than either of us had anticipated. This kind of alternative medicine impressed us.
Salzburg straddles a river, with the old city huddled at the foot of a cliff that is dominated by a fortress. After a short cog railway trip to the fortress level, a further climb of many steps brought us to a medieval room on the top floor. There, a chamber group played Mozart, this time with a setting sun bathing the baroque city below. Salzburg does know how to mix the old and the new. From our room in the modern Sheraton Hotel we could see the illuminated fortress through the leafy trees of the adjacent Mirabel Gardens. Meanwhile, B?r?nice was beginning to outwalk me!
Mozart's Salzburg birth house and the apartment in which he lived and worked during his earlier years can be visited. The collected memorabilia are extraordinary, and with even more in Vienna and Augsburg-including frank personal letters, original musical manuscripts, and instruments he played as a child prodigy-combined with my wife's excellent tutelage to convert a legendary musical genius into a very real person.
I also spent one afternoon at Salzburg's 5-year-old Paracelsus Private Medical University, the first medical school in Austria that is not under government ownership and control. Bedside teaching in small groups with under 100 students enrolled per year (in contrast to up to 2000 in state schools) is also a first. So is the emphasis on humanistic, personal, and interdisciplinary medicine. Paracelsus students pay ? 8000 per year for what is free elsewhere. It may help that one third of Paracelsus graduates are guaranteed jobs at university affiliates. Nothing similar is found in the 3 state schools. Austrian primary care physicians are still at the mercy of the social insurance system, but their income is sufficient to attract German physicians to cross the border to compete for jobs.
On to Vienna, one of the world's greatest cities, where Mozart lived until his death, and a bargain compared with London or Paris. We fortunately opted to stay in the Museum Quarter at the boutique Das Tyrol Hotel. From there we splurged on Mozart and front-row seats at the Berghof Theater, the Musik Verein, and the Staatsopern-names that we only read about before. We walked to the performances and talked with the musicians at the intermission. At the Schoenbrunn Palace we visited the room in which 6-year-old Mozart played the piano for Empress Maria Theresa and then jumped on her lap and covered her face with kisses?.It couldn't get better.
We could easily have spent 3 weeks in Vienna. The gritty city that I had visited decades earlier has been thoroughly cleaned and transformed into the glittering capital that matches its history. Afterward, we stopped in the Austrian city of Graz, with its beautifully preserved Old Town and incredible armory of medieval weapons as well as the German Danube River port of Passau, renowned for the world's largest organ in St. Stephen's Cathedral. Both cities have a connection with Mozart, but their major interest lies elsewhere. In Passau, I particularly liked watching the river traffic from our room at the Holiday Inn.
Augsburg, home to Mozart's father, was our last stop. His birth house is now a wonderful small museum. We stayed at the excellent Hotel Drei Mohren and ate in a small restaurant, where Mozart had entertained a female cousin ("das B?sle" in German). Their earthy relationship still raises eyebrows. Augsburg's "Long Night of Mozart" turned the entire city over to performances honoring the composer in art, film, plays, and music. We attended 2 concerts in the ornate "Golden Room" of the Rathaus, the City Hall. A celebrated saxophone quintet played Mozart in St. Peter's church, where we accidentally sat next to the district president of Swabia (the second largest district in Bavaria), Ludwig Schmid, and his wife. He and B?r?nice sang a Mozart lullaby together after the performance?he in German and she in French. It was lovely.
Amazingly, we never overdosed on Mozart. His legacy provided my wife with a great deal of pleasure after a whole lot of pain. But, truth be told, a change in medication after our return provided more effective pain relief. So, maybe a better word than "alternative" is "complementary" medicine. Still valuable, but?.
As for me, I found a reaffirmation of my own values.