Francesco Carelli, Professor of Family  Medicine, University of Milan and Rome

Attilio Giotta, internship graduate doctor, University of Milan

 Communication between hospital doctors and family doctors is a frequently undervalued  or – worse – not considered aspect of Health Systems.

This is a key aspect for diagnosis, care and patient’s  follow-up, mainly in chronic diseases, as well as  for adequate psychological / human support  for patients.  Cancers are a typical example, where, often after a first suspect by the family doctor, who prescribes most adequate exams to confirm or not, second level exams are performed by involvement of hospital specialists. 

At this point, correct communication between hospital and primary care is essential for the patient to get any possible explanation, in a process where the centre of clinical – diagnostic exams is not the disease, but the patient affected with his / her illness.  Only in this way it will be possible to involve all aspects in patients’ life, not just biological one, but also psychological, familial and social ones, taking in consideration how the illness influences and modifies  styles and habits in the patients’ life.   

Obviously, not always there is this gap in communication during the diagnostic process, but, considering the possible  negative consequences, it is essential to underline its fundamental importance so to avoid cases where patients could be left alone, in such delicate situations as cancer discoveries. 

An example of this communication deficit comes from a 62 years old male patient, with history of hypertension, arthrosis, and danger at work being employed as cleaner for cisterns.  Because of long episode of cough, family doctor prescribed radiographies that indicated multiple lung nodules.  The following PET showed mild hypercaptation at lesions’ level, associated with differentiated neuroendocrine neoplasm.   

Such results pushed family doctor to refer the patient to an oncologist, who prescribed a cycle of chemotherapy. After that, the patient never went to the oncologist for  usual follow-up.  Some time later, the patient visited his family doctor because of persistent back pain, and thorax tomography revealed  enlargement of the known lesions, mainly on the right. Persistence of pain pushed for dorsal and lumbar spine RM that showed multiple focal alterations in the signals mainly at passage L4-L5-S1, all attributed to bone metastases.  

Out of the clinical context, it is interesting to note a totally absence of controls for years.  When family doctor insisted in investigating, it was clear a total ignorance for the importance of the disease by the patient, only worrying for back pain, stopping him from work and putting  him in danger to lose the work itself.   Speaking with his family doctor,  the patient  resulted  not  informed  about the disease, its possible complications, consequences, therapies to be taken. Partially because of patient’s superficiality, admitting some disinterest about his own health, partially because of lack of information and follow up by the specialist, he had considered as not useful to continue in controls. Also, he was not addressed to go back to his family doctor, so eliminating (as here frequently happens) a key professional  referent for every necessity related to the disease.

We must underline also the total and absolute lack of communication, even just by email, between two medical professionals: the hospital specialist who, just as definition, sees the patient for a short and defined time, and the family doctor, the professional who should be in the position to follow him in continuity, horizontally during time.  This interruption in the chain of transmission of information drives, as in this case, to charge too much responsibility on patient’s shoulders. 

He / she  , because of his / her  behavior or because of other factors, remains alone, as unique ” messenger ” for news about his state of health,  so heavily affecting his own health situation although if lacking of adequate  competences.