by Maria Giovanna Faiella
These hospital departments increasingly treat chronic patients with complex needs, who cannot be discharged if there is no place to treat them in post-acute facilities or it is not possible to care for them at home. Community hospitals are not on the horizon. Intern doctors: «We expect a crisis in the emergency room again this winter»
People “parked” in the emergency room waiting for a bed to become available in the department; and then: patients who cannot be discharged from “acute” hospitals and transferred to post-acute facilities or RSAs (health care homes) because there are no places available, so they remain hospitalized in medical hospital departments. Again: long waiting lists for visits, tests, hospitalizations, which do not allow patients to be treated in the right time (and doctors to do so); shortage of medical personnel – especially specialists -; relationship between doctor and patient that becomes increasingly tense and complicated.
These are among the topics (some endemic to Italian healthcare) dealt with by the 124th Congress of the Italian Society of Internal Medicine, scheduled in Rimini from 20 to 22 October, together with scientific innovations and implications of clinical practice which, also year, they are at the center of the conference event. The oldest scientific society in Italy, with its 4,884 members, asks the institutions to structurally address the critical issues of the National Health Service – designed 45 years ago to deal with the problems of acute patients – also in light of the changes due to increase in chronicity.
The “numbers” of internal medicine
Internal medicine has important “numbers”. In Italy there are approximately one thousand internal medicine departments within 995 hospitals which, with approximately 30 thousand beds (out of a total of 220 thousand beds in hospitals), manage 13 percent of all hospitalizations of all specialties medical and surgical. A workload that increases in some critical periods, for example in summer or even in winter, but is tackled with the same staff, who are already understaffed.
About 30 percent of internal medicine departments are located in low-intensity general hospitals or in disadvantaged areas.
«For years we have been insisting that “non-highly complex” internal medicines be remodeled to provide better responses to patients’ need for care – explains Professor Gerardo Mancuso, vice-president of the Italian Society of Internal Medicine -. The other 70 percent of internal medicines are found, however, within high-level hospital facilities, where we treat complex patients with multiple pathologies, multiple organs involved and an advanced age, which require a notable commitment to intensity of care.” Among the patients hospitalized in these departments, in fact, there are mainly people with advanced heart failure, severe respiratory failure, cerebral stroke, metabolic comas and other pathologies which, once upon a time, were treated in intensive care and which today are successfully managed in internal medicine. .
«Read to review»
Internal Medicine, therefore, manages fragile patients with advanced and complex pathologies, which determine a very high “weight” of the DRG, i.e. the reimbursement given by the Region to the hospital for each specific activity, which in fact is on average lower than the actual cost. Professor Mancuso explains: «We remain anchored to a decree from 35 years ago (“DM Donat Cattin” ed.) which, in the table indicating the complexity of the departments, places internal medicine among those with a low specialty. We therefore ask for the revision of this table because it also has repercussions on the staffing plans of healthcare workers (doctors, nurses, HCWs), defined according to that table”.
As for the reorganization of the hospital network (revision of Law no. 70/2015 «Regulation defining the qualitative, structural, technological and quantitative standards relating to hospital care»), the internal medicine doctors propose, among other things, to institutionalize the sub-intensive activity in the internal medicine area. «Our proposal – explains Mancuso – is to establish sub-intensive internal medicine units in internal medicine departments that manage the most complex patients, in the same way as those existing in cardiology or pulmonology. Currently these sub-intensive internal medicine units are present in less than 10 percent of Italian internal medicine departments, but they are strategic because they respond to the need for assistance of the most complex patients who, in our departments, we see with increasing frequency and who have need for monitoring and adequate tools.”
Emergency room crisis
Another priority healthcare organization problem, according to internal medicine specialists, is the crisis in the emergency room.
In this regard, the president of the Social Affairs and Health Commission of the Chamber, Ugo Cappellacci, announced the launch of a fact-finding investigation into the situation of emergency medicine and emergency rooms in Italy.
Professor Nicola Montano, elected president of the Italian Society of Internal Medicine, explains: «The management of the emergency room is increasingly complex and puts hospital structures and those who work there to the test. It is necessary to act immediately, but this cannot be limited to increasing staff numbers and paying doctors adequately for the enormous workload. For example, – continues Montano – the problem of boarding, i.e. the overcrowding of the emergency room with people waiting for hospitalization, can only be resolved if healthcare managers understand that it is a system problem, a path problem, in which they must function entirely a number of things. There must be beds for internal medicines and we must be able to discharge patients to low-intensity facilities once they are no longer in the acute phase.”
Lack of local assistance and “blocked” hospital beds
Montano says again: «At the moment the territory is the bottleneck so we are unable to respond to all the needs of the emergency room, because we have many beds blocked by hospitalizations often for social reasons. And this has repercussions upstream, with the clogging of the emergency room. This winter too we expect yet another emergency room crisis. But it will always be like this until the system is addressed in a concrete way, involving interns and until beds are opened in the area. Community hospitals ventilated by the PNRR (National Recovery and Resilience Plan) would be extremely important. The problem is that they can’t be seen on the horizon and in any case we wouldn’t even have the doctors and nurses to put there.”
Professor Giorgio Sesti, president of SIMI, adds: «The hospital system goes into crisis if the territory does not filter admissions, if the departments are unable to discharge people because the rehabilitation facilities and post-acute departments do not accept those discharged and if the domicile does not accept. Hospital-Territory care continuity is a key point to guarantee the most appropriate care setting for patients who deserve chronic long-term care and rehabilitation. To keep average hospitalization times within the recommended objectives, it is necessary to unequivocally clarify the methods of transition to another care setting.”
More empathy and better communication: the proposal
The new generations of doctors who are being trained, in addition to traditional skills, i.e. having the “tools” of the trade of a good doctor, should also acquire transversal skills, first of all empathy and the ability to communicate with the patient, say the internal medicine specialists. Hence SIMI’s proposal to introduce teaching on the “doctor-patient relationship” already during the degree course, to better treat the patients of today and tomorrow, to then be applied during the years of specialization, why talk about the end of life with a cancer patient or heart disease is not like communicating the diagnosis of a less complex disease without serious consequences.
Professor Elena Pattini, psychologist and psychotherapist at the Parma Local Health Authority, explains: «Knowing the techniques of empathic communication and its effects on a behavioral and neurophysiological level allows us to approach the treatment of the patient from a biopsycho-social perspective, which takes into account not only the body, but also the psychological effects of being in a fragile condition. In this way, empathy becomes a protective factor for the care relationship and for the psycho-physical well-being of both the doctor and the patient. Empathic communication, therefore, continues Pattini, «becomes a fundamental part of the treatment path, increases patient trust, compliance, improves diagnoses and protects the healthcare professional from the risk of burn out».
Artificial intelligence: will it “replace” the internist in diagnosis?
What stage is artificial intelligence in the medical field? «It is forcefully entering the field of medicine thanks to its countless applications and potential – says Professor Sesti –. I believe it is very premature to think that artificial intelligence could replace the internal medicine doctor in making diagnoses and recommending the most appropriate therapy, but it will certainly be able to contribute to perfecting the tools available to the doctor for learning, updating and training in the field through simulations, advanced diagnostics. It is certainly a great opportunity also for research, because its applications can accelerate the discovery of new pharmacological molecules and the development of increasingly sophisticated investigations for the early diagnosis of chronic pathologies.”
October 18, 2023 (changed October 18, 2023 | 3:00 pm)
© ALL RIGHTS RESERVED