The document that the regional health councilors signed in recent days and the substantial investment that the NRP provides for territorial medicine have opened a debate that promises to be hot on the role and status of general practitioners (Mmg).
The first thing we should avoid is getting lost in the ideological and trade union confrontation on how much better (or worse) it is to have family doctors who depend directly on the regional health system or who instead maintain their current role as affiliated freelancers.
Worse than this, it would only be making patchy decisions, creating different systems between region and region that would not be understandable by citizens and which would risk increasing the differences in the levels of care and assistance that already characterize our country.
Instead, what we should do is ask ourselves some fundamental questions, define the desired changes in detail, identify the effectiveness indicators of the planned innovations and only at this point tackle the issue of the type of contract that could offer the best answers. I try to line up what seem to me to be the main problems.
The doctor of chronicity
Over the last 40 years, the Mmg has been essentially the doctor of minor chronicity and acute diseases that did not require instrumental examinations.
Major chronicity has long been the prerogative of hospital outpatient clinics (cardiology, neurology, rheumatology, oncology, nephrology, etc.), while acute patients who need an X-ray, an ultrasound, an electrocardiogram or other urgent examinations refer to the emergency room.
The question is whether the Mmg should do more and the answer would seem to be positive, if we consider the indications on Health contained in the PNRR and the billions destined to equip local medicine with electrocardiographs, ultrasounds, spirometers.
Naturally, it will be necessary to ensure that these tools are usefully used for the evaluation of acute or chronic exacerbated patients, and do not turn instead into useless and expensive additions to routine visits.
For the first of the two choices to be the winning one, it is not possible that the place of general medicine continues to be the surgery of a single doctor, isolated and self-referential.
It is therefore inevitable that places are built where different Mmgs can collaborate with each other and with other health professionals, taking advantage of the specific skills of each member of the group, establishing together objectives and professional development paths and evaluating their results in a logic of continuous improvement.
It seems that this is what is intended to be achieved with the community houses and hospitals, envisaged by the NRP and for the time being carried out only by a few regions in little more than experimental ways. To make these structures the true backbone of territorial medicine, many changes will have to be made.
For example, it will be necessary to provide coverage of the service of 12-24 hours a day every day of the week, while currently an Mmg has an obligation to be present in the clinic of only 15 hours a week. It will probably also be necessary to provide for a sort of internal hierarchy and a mechanism for monitoring the results obtained. It will take years to see results, and a long time will go into grueling bargaining with general medicine unions.
Home care
Then there is the issue of home care which has almost disappeared from the Mmg agenda and which should instead return to their hands as part of a management project in the area of advanced chronicity and terminality.
This assistance, which already exists under the name of Integrated Home Assistance, is today mainly provided by cooperatives of nurses that MMG often merely activates and then loses sight of. If, on the other hand, we want the treatment of patients at home to return to being a frontier of medicine, it is necessary to reinvent it from the roots.
There are new and exciting spaces that can help along this path, such as that of telemedicine and community hospitals. The challenge is to define responsibilities, agree on working hours and shifts, integrate institutions and professionals. Certainly general medicine cannot give up being a point of reference for this project.
The training course
Another point, fundamental for the inclusion of MMGs in a project for the transformation of territorial medicine, has a perspective of years, but it cannot be avoided. I am talking about the transformation of the culture of general medicine and the training path of Mmg.
The opening of the three-year compulsory training courses for Mmg, which dates back to the early years of this millennium, was an important step forward compared to previous decades when any medical graduate could aspire to a position as a family doctor (even before “Health insurance doctor”).
However, the training of Mmg remains particular from many points of view, the main one being that it is the only medical specialization that does not fall under the control of the University. The diploma in general medicine is in fact obtained at the end of a regional course whose control is, in fact, in the hands of the scientific societies of the same profession.
In this way, the preparation of the young doctors of Mmg is removed from the institutional bed of research and higher education, the university precisely, closing in on a cultural environment that tends to reproduce itself and does not facilitate openings and comparisons.
A collateral consequence (minor but not insignificant) of this state of affairs is the absolute impermeability between territorial medicine and hospital medicine. It happens, for example, that a doctor specialized in internal medicine, with ten years of hospital work behind him, must attend all three years of the regional course before being able to participate in the competitions for a position in Mmg. For university specializations, on the other hand, affinities and equivalences are envisaged that allow a relatively simple transition between disciplines that are similar to each other.
Your trusted doctor
Finally, there is the much debated problem of the trusted doctor. In fact, there is no doubt that, alongside a clinical role that is often not excessively demanding, the Mmg also exercises a very important role of adviser for its patients and mediator between the indications of specialist and hospital medicine and the needs and values of the individual.
This point must be carefully considered in at least two respects. The first is that it is a quality mediation that also includes channels of interaction and direct confrontation with specialist medicine, something almost non-existent today.
The second is that everything necessary is done to ensure that this relationship of trust is respected and, if possible, increased even in the case of a professional status of the Mmg different from the current one, as it could be a relationship of dependence or semi-dependence. An aspect that seems to have already been incorporated in the document, for now very general, which was signed by the health councilors.
At this point, and only at this point, it will be useful to verify whether a dependency relationship is able to give greater guarantees of realizing this program than the current conventional relationship.
None of the points that I have briefly listed will be able to find satisfactory answers if the government and regions are not provided with the necessary tools to intervene with incisiveness in their relationship with the Italian Mmg when it comes to passing from words to deeds to re-establish a sector of care and assistance that has been waiting for change for too many years.
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