Executive Page: American Dream 2018: Report of a Sleep Researcher

September 1, 2018

by Claudio Bassetti, EAN President-Elect

In 2 weeks, my sabbatical period in the United States, which started in April 2018, will come to an end. The word sabbatical comes from “Sabbath,” which in the biblical Old Testament was described as, “In the seventh year the land shall have a Sabbath of complete rest …” Today in Academics, it is obviously not simply rest. For me it was a break after 23 years of an uninterrupted hospital and university activity, 17 of which as chair or vice-chair of large neurological departments.

Before leaving, I made sure to discuss with my team about the needs of the department and how to best distribute my charges and responsibilities. A regular exchange was, in fact, planned (and subsequently also maintained) only with my research team. An automated sabbatical email reply was then installed and my secretary was instructed to screen my mails and forward to my private address only those that explicitly requested my answer. Finally, my private mail and phone number were made available only to very few people. The result has been amazing! In five months I received no more than 5 mails/day and 1-2 calls per week concerning my “old“duties. I also made sure to be back in my office only once and for just few hours.

After leaving Bern, I felt an unusual feeling of freedom, a situation -opposite to the usual one- in which I had much more time to think and much less things “I had to do“. My sabbatical started with snow and storms in Boston* and, after a warm and sunny summer (and a long vacation with my family in the Rocky Mountains) it is now ending, again with storms and floods in Madison**. One could imagine that these weather changes somehow reflected my state of mind and mood during the different phases of my sabbatical….

The expectations from my sabbatical were kept as reasonable as possible. My primary intention was to meet new people and explore new ideas; with this in mind I attended research seminars, lab meetings, and asked for personal and institutional visits. It is only in the very last two weeks of my stay, that I accepted to give a few talks at the Grand Rounds of the Mayo Clinic in Rochester, Rush University in Chicago, and Harvard Medical School in Boston.

After five months I return home enriched by new contacts and perspectives. Luckily, few papers and grant proposals could also be completed. As anticipated, I had much time to think, and my reflections ranged from personal to professional topics. They also included the future of EAN. Some of the issues that I had mentioned in my application for the position of President-elect, were “revisited“ in light of my American experience. Let me shortly mention four of them:

Scientific culture and interdisciplinarity: I was greatly impressed in the excellent centers that I had the opportunity to visit by the depth and breadth of scientific interactions and the atmosphere of respect in which they occurred. This reflected the competence of the individual team members, but also the contribution to the discussions of specialists from different disciplines. The horizontal hierarchy of the teams, the intrinsic motivation of the individuals, and the ability to discuss even controversial matters without confrontation appeared to me essential for the success of the interactions. How local, national and continental institutions promote teamwork and interdisciplinarity in Europe greatly varies; not infrequently, however, some of the “elements of success“ mentioned above are missing. The presence of the EAN at the national as well as at the EU level is a unique opportunity to support (and when necessary trigger) the necessary changes in structure and culture to reach scientific excellence.
General Neurology and quality of care: Neurology is undergoing an increasing fragmentation related to the continuous development of new subspecialties (more than 20 in the US). While this evolution is in many aspects favourable, it creates problems in the care of some patients (e.g., those who have multiple problems or one that is difficult to be classified) and in the training of residents. It also increases the healthcare costs. Richard Hughes and I wrote a while ago about this issue, stressing the importance of “general neurology“ for the future of neurology ¹. During my stay, I had the opportunity to meet with a few “Neurohospitalists“, members of a society which was created about ten years to respond to the challenges created by the increasing demands (and complexity) of (in)patient care, and the decreasing clinical competence of many subspecialists². Today, there are in the US more than 2,000 neurohospitalists active not only on the hospital wards but also in the emergency rooms and the outpatient clinics. While some aspects of this neurological subspecialty remain still open, its role in improving the care of patients and reducing healthcare costs appears to be established. The EAN should discuss with the National Societies how to maintain an adequate training of general neurologists and a sufficient (clinical and academic) recognition of this “species in danger“ also in the years to come. In addition, an exchange of the EAN with the AAN and the Neurohospitalist Society on these topics could be of mutual interest. This would also contribute to the definition of reasonable safety and quality metrics in neurology, which are greatly underdeveloped ³.
Residency program and the Clinical Neuroscience Track: To maintain the attractiveness and quality of residency programs in times of increasing financial pressure and changing societal and generational expectations is a challenge for all medical societies, including neurology ^4-7. For our speciality, which has always been strongly rooted in neuroscience, it is essential to support the careers of Clinical Neuroscientists, those neurologists who will be capable also in the future to link basic and clinical neuroscience (two worlds which tend increasingly “to drift apart“). Such a support requires enough academic staff members and finances. While the ratio between academic and clinical staff is often >2 in top US institutions, it is typically <0.2 in many European departments. One of the main reasons for this discrepancy it is that the majority of academic positions in the US are dependent on fundings from research grants. Conversely, the few academic positions in Europe are typically fixed and subsidised by the Universities. Both models have shortcomings, but more competition could increase the productivity and efficiency in the European system. However, who is going to pay for the creation of more academic staff positions? And how shall we finance the careers of talented “Clinical Neuroscientists“ who cannot (yet) apply for research grants? Models have been developed in the US and in some European countries (including Switzerland) but an international exchange could give rise to new, creative and promising approaches.
International collaborations: In most teams that I visited I was impressed by the high number of clinicians and scientists coming from other continents, including Europe. While language may be one “practical“ explanation, it was the scientific excellence and culture that motivated scientists over decades to move to the US. Today, this flow is decreasing, in parts because of the deteriorating political climate but also because of the increasing bureaucracy in the American educational and medical world (one of the few “dark sides“ of my sabbatical). The support of exchange programs across different European countries is one of the key-missions of the EAN. In the future, a partnership with the American and World Neurological Societies could increase the volume, quality and potential impact of those programs while also supporting the development of residency and scientific programs in less advantaged countries.

My five months in the US have been a memorable experience. As in my previous visits to the US in 1982 (as a student), and in 1994-5 (as a research fellow), I have been fascinated by how rich and dynamic neuroscience and medicine in general are in this country. At the same time, I had to realize that the brilliant academic world that I just described sadly co-exists today with a growing population of people who is not benefiting from it. The country is facing tremendous socio-political challenges and tensions. The current administration must be seen (in my modest opinion) rather as a symptom than the cause of the situation. Still, I am (and I want to be) confident that the US will “survive“ the current turmoil, successfully address its problems (as it has done many times in the past), and return to be a country of unique opportunities and equality, which I so much enjoyed visiting during my sabbatical.

*Harvard Medical School, at the BIDMC and MGH (with Prof. C. Saper, Prof. T. Scammell and Prof. A. Videnovich)

**University of Wisconsin (with Prof. Tononi and Prof. C. Cirelli)