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When the national health system was taken by surprise by the coronavirus epidemic that began last February, family doctors were the category that more than others had to fend for themselves to face the emergency. Since then, many things have changed, and the experience acquired by territorial medicine has been added to an enormously superior efficiency of the health machinery that surrounds it. In view of the autumn, and of a possible “second wave of infections”, the family doctors, like the rest of the health system, will be more prepared and equipped.
Although six months have passed, however, there are major issues that have not yet been resolved, and above all there is a concern that paradoxically, in the most acute phase of the epidemic, was secondary: normal flu, with its symptoms in part. similar to those of COVID-19.
“The problem will not be only if there is a second wave, the problem will be to distinguish if there is,” explains Silvestro Scotti, national secretary of the FIMMG, the main union of general practitioners. “When influenza syndromes begin in the fall, if they are particularly virulent, there will be an initial symptomatic phase that is virtually indistinguishable between patients.” In addition to the coronavirus, therefore, the justified suspicions of anyone who falls ill with the common flu or pneumonia of having contracted COVID-19, will initially put pressure on the health system. And this pressure will inevitably affect the first link between citizens and healthcare, that is, family doctors.
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The importance of territorial medicine in an epidemic became evident last spring, when it was realized that a response that favored health care in the home of patients, making less use of hospital admissions, was much more effective. The poor coordination of family doctors and the purely hospital management of the crisis were, in fact, some of the determining factors of the extremely serious number of victims of the epidemic in Lombardy (along with several others, some still to be really understood).
The difficulties and frustrations of Lombard family doctors were well documented. Things have improved a lot since then, explains Dr. Michele Marzocchi, who has his office in Milan. “But now things are going well because at the moment there are no critical problems: yesterday I saw the first positive swab among my patients since April.” In autumn, conditions will continue to be very different from last winter, explains Marzocchi: “At that time the virus had been going unnoticed for months and today there are no restrictive or hygienic measures.”
Among the most important improvements in working conditions for family physicians is the introduction of the USCA, units often made up of young doctors who are tasked with following positive and suspect patients at home. Another is the possibility of requesting a nasopharyngeal swab for your patients for several months. At the moment it also works with a certain speed, more or less 72 hours from the request is the result ”, explains Marzocchi. But already in recent weeks, with the mandatory swabs in those who return from a foreign country or Sardinia, there have been overloads and slowdowns: “So when the flu season arrives we will have to see.”
Now that the coronavirus has an endemic transmission, anyone with symptoms such as fever, cough or breathing difficulties will have to be treated as a suspected case by family doctors: and therefore all the precautions of an established positive will have to be used. To reduce these cases, doctors and health experts have long emphasized the importance of extensive flu vaccination coverage: the fewer people who take it, the fewer false alarms there will be.
If the time that elapses between requesting a swab for a suspected case and determining its possible positivity is excessively long, there is great uncertainty about what measures should be applied and how. The problems will be more or less the same as in March and April for people with suspicious symptoms who could not be tested: can their partners go to work or go shopping? Who will be in charge of your vigilance and assistance, in the uncertain phase between flu and COVID-19?
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“If you look at the current guidelines, there are procedures that formalize only the part up to the request for the swab: and then?” Scotti asks. As already happened in the first months of the epidemic, right now there is a risk that the problems will also affect the therapies to be applied, about which there are often contradictory indications. Then there are the drugs used to treat the symptoms of COVID-19 that have been withdrawn from local pharmacies, reserving them only for hospital ones: “in many places you have to involve hospitals to be able to administer antivirals,” explains Scotti.
Another great difficulty in the first months of the epidemic had been finding personal protective equipment, from masks to gloves and gowns. Supplies to family doctors by the national or regional health system had been insufficient, if not absent, and everyone had had to buy them themselves on the market: even in the weeks when a professional mask could cost tens euros in certain pharmacies. . Not much has changed: there are still no supplies, says Scotti, but the difference is that now there are no major problems in purchasing the devices, whose production and distribution has increased enormously.
To speed up the “suspect” phase between the onset of symptoms and the swab result, some have suggested that family doctors themselves perform swabs and then send them to the appropriate laboratories for analysis. This would eliminate the phase of taking over the notification by ASLs, which is not homogeneously efficient (not always computerized, for example) and has a high risk of overload. “The family doctors will have to go see people at home, they will have to do the swabs themselves. If we don’t re-establish this system whereby people don’t go to hospital, we won’t be able to do it, ”said Giuseppe Ippolito, scientific director of the Spallanzani Institute in Rome, for example.
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So far no decisions have been made in this regard, but it is still not a simple matter. By participating in the research with serological tests for teachers, the category of family doctors wanted to signal that they are ready for such an operation, says Scotti. But due to the particular contracting of general practitioners, halfway between freelancers and state employees, at this time the responsibilities of systematically exposing themselves and the people who work on the study to suspected patients would fall on the doctors themselves. “A bit like the director of a hospital,” explains Scotti, with the difference that the contract for family doctors does not include protections for a case of this type. “The problem is that the contract does not foresee an emergency situation: I am not speaking from the point of view of remuneration, but of safeguards, of clarity in tasks and functions.”
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