Happy Monday! I hope you all had a good weekend. Other than my 15 mile long run this weekend revolved around getting Bo home from the hospital and on the road to recovery. After sharing the news of Bo’s surgery on social media this weekend many people asked for his perspective on whether having surgery was different in Switzerland than the US. Luckily, or unlucky for us, he has this perspective since this is his 2nd ACL surgery! Based on your requests, today’s post is a guest post from Bo!
I’m obviously not a doctor so I need to apologize upfront for any medical inaccuracies or misinterpretations that I might make. These are simply the observations of a patient that has a somewhat unique perspective on the differences as I have had the surgery now in both countries. I would also note that seven years have elapsed since my first surgery and that some of the differences might be due to advancements rather than geographic differences. Additionally, some of my observations might be clinic / hospital specific so I’d be very interested to hear of any differences in the experience of others. Finally, I need to express that, in both cases, I had great health insurance, a fact for which I am quite thankful. I am not covering the specifics as to how the different health insurance regimes work as that is fairly nuanced and dependent on many different factors. Suffice it to say that I had wonderful care in both cases without having to bear too much of the cost myself.
![IMG_1405[1]](http://www.healthyhappierbear.com/wp-content/uploads/2014/08/IMG_14051.jpg "IMG_1405[1]")
Background
In 2007, I tore my right ACL and meniscus playing basketball – it was incredibly painful and afterwards I could barely walk for a month. The surgery was done at Bryn Mawr hospital and was a staged reconstruction: the doctor first repaired the meniscus and then two weeks later went back in and repaired the ACL. This year, I tore my left ACL while skiing with no pain, swelling or meniscus damage – my leg slipped underneath my body during a fall, I heard a pop and then my leg felt slightly less stable than it had before. The surgery was done at HUG (Hôpitaux Universitaires de Genève). Given that I had no pain, I was able to still swim, bike ride and walk which is why I waited until now to have the operation despite being injured in March.
Difference #1 – Initial Orthopedist Visit
In my experience, in the states, when seeing a specialist, you might spend most of your time in the doctor’s office with a nurse or a PA. However, the doctor that examines you (perhaps once before an MRI and once after) is your doctor (i.e. the one who will be performing the procedure). In addition, even if the MD is not able to spend a lot of time with you, the nurse or PA can answer any questions that you might have. In Switzerland, I never saw a nurse until I was in the hospital for pre-op. All the time before was spent with an MD. However, this MD was not a doctor who was doing my surgery, but rather a resident who worked for the head of the department. This might be specific to my case as the doctor performing my surgery was the head of orthopedics at HUG but it was still a little nerve-wracking having never met my surgeon until I was already prepped and about to go into the OR.
Difference #2 – Scheduling and Administration
In the states, scheduling a surgery has always seemed fairly simple. As you leave your assessment appointment, and receptionist or administrator tells you that the MD has slots at these dates and times available and asks what works for you. If you aren’t able to figure out exactly what works for you, a few easy emails will sort it out. Here in Switzerland, things work very differently. First, everything is done via mail rather than email. I was told after my appointment that I should expect to receive a letter in the mail instructing me on the next steps. The letter that I received (obviously in French) told me the date of my surgery and the date of a separate anesthesiologist appointment that I would have to attend. These dates didn’t work, so I had to struggle to reschedule by calling my surgeon’s secretary. She spoke no English, and my broken French was barely satisfactory to sort everything out. Ultimately it all worked out but we were quite worried at one point that this was going to cause the surgery to be delayed by months.
Difference #3 – Outpatient vs. Inpatient
In the states, as far as I’m aware, ACL surgery is almost ALWAYS an outpatient procedure. This is not the case in Switzerland. In fact, in Switzerland, it is ALWAYS an inpatient procedure and I was given almost complete discretion as to how many days I wanted to stay in the hospital. My doctor said that some people go home after one night; many choose to stay two, and some stay even more. Given the control that the health insurance industry has over such matters in the US, this would never fly there. I chose to stay two nights as I had to make it up three flights of stairs on crutches to get into our apartment.
![IMG_1467[1]](http://www.healthyhappierbear.com/wp-content/uploads/2014/08/IMG_14671.jpg "IMG_1467[1]")
Difference #4 – Procedure for Leaving the Hospital
Hospital discharge, for inpatient and outpatient, is VERY controlled in the US. In my experience, the staff has to confirm that you have someone there to drive you home, they complete a set of checks and discharge paperwork that you sign, and in many cases, the nurse or orderly wheels you to the front door and helps you in the car. The process in Switzerland seemed very strange to Americans used to the former. They told me that I could go home anytime after noon the day following the surgery. I chose to stay, and the following day when it was time to go, there was hardly anyone around to help us. I buzzed the nurse just to confirm that I was okay to leave, and she effective said: “sure, just make sure you have all your stuff.” Ashley even had to locate a wheelchair herself as the walk from my room to the exit was close to half a mile.
Difference #5 – Pain Management
In the states, I was given pretty heavy drugs (hydrocodone, oxycodone, etc.), and I don’t recall ever being in too much post-op pain. That said, I do recall feeling as though two weeks of taking fairly heavy opiates on a daily basis was not a good thing and stopped because it got a little scary. For post-op pain relief here, I have been given acetaminophen (e.g. Tylenol) and ibuprofen (e.g. Advil) to take on a daily basis for a week. I’ve also been given tramadol, a much weaker opioid to take only in case of extreme pain. The approach is both good and bad. There is obviously much less risk of any opioid-related side effect, but on the second night in the hospital for example, the swelling got a little out of control and I was awake in fairly excruciating pain from 1:30 – 5:00 AM. The nurses had to give me an IV anti-inflammatory which obviously wouldn’t have been possible if I hadn’t been in the hospital.
I hope this has been interesting, and I would love to hear if anyone agrees / disagrees with anything that I’ve written here.
I’d actually be interested in how health insurance works there and how you pay for this, if it’s not too personal. Is it more difficult for foreigners?
He doesn’t pay for it! Free health care in Europe! Even for foreigners.
Liza, you are partially correct but its a little more complicated. Heath insurance is obligatory in Switzerland and the lowest form for only about CHF1,200 per year basically will pay for all these type of procedures with effectively no co-pay. That said, I have private ex-pat insurance through Ashley’s company which allowed me to have the head of the department do my surgery. We definitely know how fortunate we are in this regard.
Let me know if you have any other Qs.
Bo
Hey Jessica,
Great question and I actually edited the preamble to mention the fact that I’m not touching this point. I was very fortunate to have great insurance in both cases. Liza is kind of right, heath insurance is obligatory in Switzerland and the lowest form basically will pay for all these type of procedures with effectively no co-pay. That said, I have private ex-pat insurance through Ashley’s company which allowed me to have the head of the department do my surgery. We definitely know how fortunate we are in this regard.
Let me know if you have any other Qs.
Bo
Wow — really eye opening, actually. Very interesting to read!
I don’t have much (…okay, any) experience with meeting with physicians at an office prior to surgery, but patients who are admitted to the hospital for surgery find it crazy that they don’t actually meet their attending surgeon until they’re going into surgery. (If then, actually.) The residents do all the work, especially when it comes to seeing patients in the hospital. In a teaching hospital, it’s just how the system works and makes sense to someone who works in the system, but I understand how patients think it’s crazy that they may not ever meet their attending surgeon.
Tylenol is a highly underrated drug, and I find it interesting that they had you rely on that. My patients look at me like I’m crazy when I suggest giving them Tylenol. (Is it “prescription strength”? There’s no such thing as prescription Tylenol! Anyway…) I like the idea of relying on non-narcotic pain relievers unless the pain gets worse. As a side note, we generally don’t give Advil in the hospital since it increases the risk for bleeding – although it is also a great drug. People don’t realize they don’t always need the heavy stuff!
I’d be interested in knowing the legal aspect of the medical world in Switzerland. So much of what we do in the US is to cover ourselves from any malpractice that might happen (such as the lengthy discharge process). I’m not well versed in international health care plans, but I believe France has limitations on suing medical professionals – I think you can’t sue at all, which decreases all this crazy quadruple checking of everything which costs more and takes more time. I find it fascinating how other countries run their health care systems since we’re clearly doing something wrong here in the US!
Okay, end of novel. Hope you have a speedy recovery and thanks for sharing your experiences!
Hey Susan – your commentary is so interesting. The attending physician thing is interesting though I think that I have had surgery at a teaching hospital once (Hospital for Special Surgery in NYC) and even then I met the attending before my surgery. Do you think its more case by case or maybe HSS isn’t a full teaching hospital, I’m not sure.
On the pain meds, I totally agree with you, and have been fairly surprised, that 1,000mg of acetaminophen is a highly effective analgesic. I think in my case (would assume with most joint surgeries too) that the combination with ibuprofen (or some other type of NSAID) is key though because the only time that the pain has gotten out of control is the couple of times that the swelling has gotten out of control. I actually wished that they had prescribed something else that I could take more (400mg, 3x per day) as the dose doesn’t help control the swelling enough at night.
You’re thoughts on the discharge procedures were exactly what I was thinking as well. I’m not sure what the tort laws here are but I know that suits don’t happen with any degree of the regularity that they do in the US. The most interesting thought that this whole thing has provoked though is exactly how much cost our legal system injects in the medical system. If they have absolutely no issues with two inpatient nights for something like this and can charge CHF1,200 per annum for basic coverage, we have to be doing something really wrong in the US.
Bo
I believe the ortho residents that we get at my hospital are actually employed by HSS, so while I don’t fully know their system, I’m pretty sure it’s a teaching hospital. The difference between your surgery (not sure what you had done at HSS, but I believe they mostly do scheduled surgeries versus trauma) and what I see in the hospital is that you had planned surgery versus coming in with a broken leg. If the surgery is decided upon at a scheduled appointment, you’re most likely talking to the surgeon who will be doing the operation at a later date. If you come to hospital (via the emergency room), then your care is taken over by a orthopedic team which consists of residents and an attending. The residents will be doing most of the scut work, and you may or may not see the attending. (It would be worth noting that most of my ortho patients were straight forward and pretty basic as far as breaks go.) One of the huge issues in hospital healthcare is the physician presence, as many times they just run in and out of patients’ rooms, and patients have no idea who is who, nor can they necessarily even name their attending/surgeon. It’s easy to see how people can get confused and/or frustrated with the system.
The use of ibuprofen is very hospital specific – it’s mainly not used because of the increased risk for gastric ulcers, which hospital patients are at higher risk for in general (increased stress, new medications, etc.). Did the hospital give you prophylactic acid reflux medications (such as Nexium or Protonix) or blood thinning shots (prophylactic against blood clots…such as heparin or Lovenox)? This is just me being nosy – basically every patient in the hospital in the US gets them, I was just wondering if they do the same in Switzerland.
1200 franc is so cheap, and it sounds like it provides for care that is more patient driven rather than insurance driven. I do believe that required insurance for everyone helps to keep the costs down, as hospitals provide a lot of free care to uninsured and undocumented people who cannot afford to pay. The care is already being provided, but I have no idea where the money is coming from! I would be interested in knowing what compensation is like (not that I expect you to know the answers!), as many people like to the say the high costs of healthcare are due to physicians being paid so much. Physicians in France make significantly less than their American counterparts, but they also don’t have to worry about malpractice insurance (which can be extremely burdensome) or medical school loans since medical education is very cheap there. Not saying that American and French physicians are hurting in the financial department, but it gives a little perspective to the varying costs.
And I’m just being nosy again – but what was your experience being an English speaking patient in a foreign hospital? Did staff speak English, or did you have to utilize translation services? We have many non-English speakers admitted to the hospital, and I’d be curious what it would be like on the other side.
My apologizes for the novel again, and if any question is too invasive, please feel free to disregard!
Interesting to read. I’m a Canadian and have had surgery here but nothing serious and thankfully no experience with surgery otherwise 🙂 hope Bo gets feeling better soon!
Thanks for the nice wishes Pam – i’m already feeling better!
Bo
As I mentioned on Twitter, my ex had similar surgery last summer in London, on the NHS (i.e. with no paid-for medical insurance). I can’t remember the exact details, but he had torn both his ACL and PCL (and maybe some other part too!) during a martial arts accident. His knee basically bent back the wrong way when someone landed on it.
It’s funny that you mention about the (lack of) time spent beforehand with your surgeon, as my ex only had one or two ten minute appointments and I can remember thinking this didn’t seem long at all for someone that was about to start rooting around inside your knee!
I am very surprised that this kind of surgery could be offered as an outpatient procedure, I guess it depends on the severity, but in my ex’s case he was so out of it on morphine after the op that there’s no way he could have gone straight home. I was actually a little scared by how dazed he was. He also had some very minor complications unrelated to the surgery, which I was glad he was in a hospital still, so they could monitor him.
Generally, the post-op care was very sporadic and not that brilliant, I had to do a lot more than I expected, in terms of going and physically finding nurses to find out what was going on, getting food and drink, helping him to the toilet and ensuring that he was being brought enough painkillers.
One man on the same ward discharged himself with no one to escort him home as he got so fed up waiting to find out what was going on! Once we’d had the okay to be discharged, we had to wait for painkillers to be brought up from the pharmacy. This took between 5 and 6 hours because they got misplaced on the way up. We then found out they were only giving him paracetamol anyway, which we just went and picked up from the shop outside ourselves anyway! And we definitely weren’t escorted to the door of the ward, let alone further.
Thank you so much for sharing this Lissy! My husband was amazed! I’m glad we did the surgery in Switzerland! 🙂