General medicine: the territory is not a periphery of the hospital

Once upon a time, there was feudalism. It was not just a political system, but a certain idea of the world: power descended from above, granted territories, distributed functions, assigned roles, demanded loyalty. The territory was not thought of by those who inhabited it, but by those who governed it. The historical comparison must be handled with caution. Feudalism was a web of personal relationships of loyalty, protection and dependence. But therein lies the strength of the metaphor: the risk, today, when talking about territorial healthcare, is to return to a similar logic. No longer the fiefdom with the castle, but a system that looks at the territory from above, as something to be organised, assigned, colonised. Reforming the territory starting from the hospital often means forcing the perspective. It is like looking at the countryside from the castle tower: you see the map, but not the people. One sees flows, accesses, discharges, codes, beds, but not what constitutes general medicine: longitudinal relationship, biographical knowledge, trust, proximity.

The article by my colleague Massimo Massetti, published in Il Sole 24 Ore on 20 May, has one merit: it puts the GP back at the centre of the discussion. To say that the GP is 'a protagonist missing from care' is a fair provocation. However, the conclusion needs to be discussed. The risk is that general practice is celebrated while being turned into something else. First the family doctor is invoked, then he is placed within models thought up elsewhere. It is a subtle form of apparent recognition: I call you the protagonist, but I write the script without you. We, on the other hand, are here. Not as nostalgic custodians of a past to be defended, but as a generation in the middle: the one that chose general medicine 'by choice'; the one that has known the doctor on call, the wait for the convention, the fatigue of entering a saturated system. We are here to discuss our work, with concrete proposals. Bringing general medicine to places shared with the other actors of care is a necessity, but we must not risk that, in order to bring GPs to common places, we use a narrative full of clichés.

The technocratic fallacy is worrying: thinking that the problem of care is above all a problem of organisational architecture. And here the issue of the training of future doctors opens up. The Italian university too often continues to train small specialists before training doctors. It teaches them to look at the organ, the district, the procedure, the parameter, but struggles to educate them to see the whole. The young doctor knows an increasingly small part of the human body, but risks losing the whole person. The world that awaits us is not made up of patients sorted by chapters in a textbook. It is made of frail elderly, multimorbidity, chronic pain, loneliness, tired families. This world needs a medicine that can hold it together.

In Plato's Carmide, Socrates recalls that one should not treat the eyes without the head, nor the head without the body, nor the body without the soul, because the part cannot be well if the whole is not well. General medicine must save what it does best: give continuity to care, face to proximity, clinical sense to complexity. The future of territorial healthcare is not built by returning to a feudal logic. It is built by recognising that the territory is not a periphery of the hospital. Only with intent and vision can a system be reformed. We are here.

*SIMG Directorate