Interview with Dr. Giuliano Piccoliori, physician in South Tyrol and scientific head of the Institute of General Medicine and Public Health in Bolzano on the current situation and future of general medicine.
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During the COVID-19 pandemic, the workload of physicians and all healthcare professionals increased considerably. In particular, the pressure of the health emergency was, and still is, high on general practitioners, who were able to cope with the situation despite structural deficiencies and contingent difficulties. Yet, general practitioners continue to be singled out by a section of public opinion and some of the media as the weak link in the National Health Service. On social media, some people even rely on self-therapy groups to cope with alleged shortcomings of their GPs, putting themselves in the hands of (supposedly) unknown physicians. We spoke to Dr. Giuliano Piccoliori, a general practitioner in South Tyrol and scientific head of the Institute of General Medicine and Public Health in Bolzano, Italy, about this topic.
If I had to answer with one word, I would say devastating. We had to deal with something totally new and unknown, learning to change our knowledge and procedures within a few weeks. We changed the organisation of our work. All or almost all of us introduced a rigid system of appointments by telephone booking to avoid crowding and spreading the virus.
In addition to our daily work, which was already demanding before the pandemic, we have added the management of COVID-19 patients or those with symptoms suggestive of COVID-19. Patients with symptoms of COVID-19 are first of all swabbed, either by us in the outpatient department if the facility allows it or otherwise in another public facility. The results of the swabs must then be reported on the provincial platform. In the event of a positive result, monitoring of the symptoms and treatment appropriate to the individual case begins. This is followed by contact tracing, which has more than once created tensions with patients who do not want to be reported as close contacts, for reasons one can imagine. Another workload has come from the vaccination campaign. We are all informing our patients, and there are those who want to participate directly in the administration of the vaccines. I estimate that our workload has increased by an average of 30-40%.
A job that we have bitterly discovered is anything but safe. We ourselves and our families are at risk. And that makes it all the worse.
I do not feel like saying that the pandemic has highlighted the existence of communication difficulties or even the relationship between the hospital and the territory. These difficulties had already been widely known for decades and had been continually denounced. I believe that the main reason for these difficulties lies in the fact that general medicine, the main interpreter of primary care, continues, in Italy and now only in Italy, not to be considered an academic discipline like the other branches of medicine. It is not taught during the university degree course and it is not a specialty course. Therefore, poor knowledge and unfortunately often a poor consideration of general medicine exists on the hospital side.
Perhaps there is also an unexpressed inferiority complex compared to other disciplines. Unfortunately, also among new graduates the specific training course in general medicine is still experienced as a second or third choice, if not even a choice of necessity. As a consequence, there is often a lack of awareness and pride in their profession among new family physicians. Restructuring the base, starting with the training of physicians, could begin to bridge this gap between hospital and territory. It is not only a question of facilities or resources, it is also a question of mentality. The general practitioner must have the same dignity as other specialists, in the eyes of other specialists, in the eyes of patients, and first and foremost in his or her own eyes.
In my area, the USCAs never started because we continued to take care of our patients at home. In March 2020, when we were in the red zone and we had hundreds of patients with COVID-19 and we were getting sick one after the other, when we really needed them, the USCAs had not yet been conceived.
In my opinion, USCAs represent the failure of community medicine. A primary care medicine organised in the Anglo-Saxon sense, with associated physicians and a large number of administrative and nursing staff, would have been very well able to take care of COVID-19 patients on its own. This has been the case in Germany and Austria, for example, countries I know very well.
"Complex organisational forms are needed, which, in the same structure, bring several general practitioners together with administrative and nursing staff, possibly with the addition of other professionals, such as physiotherapists and psychotherapists."
(Dr. Giuliano Piccoliori)
This is an incredible phenomenon. These groups claim to manage and treat people with an as yet partly unknown disease without ever having seen them, without knowing their history, except on the basis of a medical history which obviously cannot be complete and exhaustive. But what is even more incomprehensible is that there are patients who rely on them. We need years of knowledge of our patients in order to be able to deal with minor problems over the phone, and yet these groups pretend to treat such an insidious disease as COVID-19.
Fortunately, as we know, 95% of cases of COVID-19 are benign and recover spontaneously. However, there are the 5% that need early recognition, immediate treatment based on the evidence of hundreds of studies conducted worldwide, and constant monitoring that can only take place in hospitals, where, as we know, oxygen therapy, assisted ventilation and even intubation may be necessary to save people's lives. There is a real risk that the 'care' provided by these home care groups will fatally delay the use of appropriate treatment or do harm by recommending drugs that have no efficacy and are certainly not harmless, such as plaquenil or ivermectin.
It has to be recognised that, in some ways, these online groups, these organisations, fill a gap in the trust and activity of primary care. Evidently we have not succeeded in gaining or maintaining the trust of all our patients, and again the cause is an organisation of our work that is obsolete and insufficient to cope not only with the pandemic emergency but also with the care of the chronically ill, the frail and palliative care in the broadest sense of the term.
I believe that the problem is one of context and structure. In the first phase of the pandemic, for example, general practitioners could not even perform their role because they lacked protective equipment such as masks, overalls, disinfectants and gloves. In those circumstances, the population did not always understand that, without protecting themselves, the physician would endanger his patients, becoming himself a vector of infection.
Patients reproached me for not visiting them, yet in March last year I was at home, with COVID-19, handling 90 calls a day. Patients thought we didn't want to do our part, just as many were disoriented by the constant changes in protocols. Medicine is a living, evolving science. We know it, they don't. Perhaps we also need to rethink the communication surrounding medicine. The trust of our patients is the basis of our profession. To regain it and maintain it over time, we need to redefine the context and structure in which we operate.
The general practitioner continues to be the reference professional for every health problem, he is the gatekeeper, the filter between the citizen and the health system and at the same time the guardian, the coordinator of the patient within the NHS. His role is very complex because he has to deal with a very wide spectrum of problems, often at an early stage and therefore even more difficult to identify. He is certainly the physician appointed to deal with the chronically ill, who almost always have several pathologies; he is the only medical figure who can really carry out primary prevention, health education and prophylaxis.
I have been hearing about complex organisations in general practice for 20 years. They have been called in the most varied ways: UCCP, UTAP, MGI, Health Houses and now Community Healthcare Houses. In the end, they are basically always the same thing, complex organisational forms that gather within the same structure several general practitioners together with administrative and nursing staff, possibly with the addition of other professionals, such as physiotherapists and psychotherapists. These are the Anglo-Saxon practices, which have existed for half a century. But there are also Spanish and Portuguese health centres, and Austrian primary care units, one of which I visited this weekend.
In Italy, attempts have been made on several occasions to introduce these complex forms, which certainly go in the right direction. For reasons that I do not fully understand, however, they are not completely established and they involve only a marginal percentage of general practitioners. Except in the Veneto region, where 20% of the general practitioners are part of the MGI (Medicina di Gruppo Integrata, Integrated Group Medicine). We know that those who work there would never leave and that the patients are also satisfied. In addition, inappropriate use of emergency rooms and specialists would be reduced. I believe that these forms should be encouraged even more, while maintaining the possibility of outpatient clinics in remote areas. Otherwise, general medicine risks extinction.
Physicians have to be physicians and take care of their patients. Others must take care of other things. Today, many physicians are not able to do their best with their patients because they are burdened with a thousand other management and administrative tasks. I do not believe that the problem lies in the professional classification, the problem is not whether to be an employee of the SSN (Servizio Sanitario Nazionale, National Health Service in Italy) or whether to be a freelancer. It is a problem of mentality, again. We have to abandon the romantic idea of the physician who alone, with his leather briefcase, is able to treat his patients.
This physician is not able to cope with the new challenges that appear before him. General medicine needs to be taught in the same way as other medical specialities, with equal dignity. We need a new context, in which the general practitioner works side by side with other physicians and other key healthcare and support figures. Investment is needed in facilities and technology. A general practitioner's office must have an ultrasound and an electrocardiograph and it is unthinkable to do this work without an initial diagnostic assessment of many patients.
This is the only way to take care of chronic patients, frail patients (not necessarily chronic), palliative patients (which are not only cancer patients). These patients represent the real challenge for general medicine, because these patients have to leave the hospitals and be treated on the ground. Reorganising the healthcare system means investing more energy and resources, but above all treating our patients better. And this reorganisation can only be effective if it starts from general medicine.
*Giuliano Piccoliori is a general practitioner in South Tyrol and scientific head of the Institute of General Medicine and Public Health in Bolzano. Previously he was also Director of the South Tyrolean Academy of General Medicine (AcAMG), which was responsible for the development of the three-year training in general medicine and involved in various research projects on local and international health services.
1. Dedicated medical teams (called “USCA”—“Unità Speciale di Continuità Assistenziale”), are assigned to monitor COVID-19 patients at home through daily calls or home visits.