Luca Puccetti, MD, General Practitioner, Teaching Coordinator, School for Specific Formation in General Medicine of Tuscany – FORMAS – Pisa Branch

Francesco Carelli, Professor of Family Medicine, Milan, Rome and London; EURACT Council, Director of Communications

Family doctor  (even agiographically) is  well recognized as a person-committed doctor rather than a disease – oriented physician.

In the common sense this expression is taken as “a doctor who is attentive not only to technical aspects but also to  human and social relationships”.  So, family doctor is considered a physician who takes overall care of a sick person in his family and social environment, not only a technician  who cures a disease.  

General practice, in different ways according to different countries, is strongly associated with indexes of better overall health and lower costs, however Primary Care is now on the verge of collapse due to a dysfunctional financing and delivery system. In US very few young physicians are going into primary care and those already in practice are under such stress that they are looking for an exit strategy. (1). Also general practice has a conflict:  to do not enough, while specialist medicine tends to do too much. General practitioners do not let third parts earn , they, in fact, do not prescribe innovative, expensive drugs, neither adopt expensive medical devices for diagnostic or therapeutic purposes and therefore have few resources to develop and to promote themselves in the media and in decision makers, because they are not interesting for the various decision makers.


To motivate Family doctors to get targets (that are almost always uncritically accepted from international guidelines proposed by other specialists, often full of conflict of interests by stakeholders) some models of proactive medicine have been proposed, with disease addressed consultation services, separated like in other specialities and  paid  for performances, with process or surrogate indicators and poor  results  in terms of serious endpoints, as reduction in mortality or hospitalization rates ( 2, 3 ).  At  the same time the needs of accountability generate increase of bureaucratic tasks and of costs, and further reduction of time devoted to patient care. So it will be necessary to provide standard  care by lower grade health professionals. Furthermore,  the idea that informatics and telematics  can solve any problem is just a delusion.  As it was shown by the University College of  London independent review of Summary Care Record in UK (4), triumphal expectations and huge investments  didn’t produce the expected results, on the contrary there are serious risks for privacy. Evident examples of these risks are the fight for opting out from the Spine and the request by Police to gain access to ciotizens’ health information, causing potential risks for the patients reluctant tio share vital information with their doctor ( 5-9 ).

In recent years, stakeholders have invested  huge sums to medicalize more and more human life. The  same WHO definition of health ( 10)  is misleading and dangerous to the sustainability of public health  and universal access to health care and it has been used to  expand the margins of medical intervention. The total control of the media by advertisers, the uncontrollable circulation of false or exaggerated health news via social networks, increase  noise and  generate unrealistic expectations in the population. This results is an increase in litigation for alleged medical malpractice that, in turn, results in an increase in costs for defensive medicine. Supporting individual specialist disciplines, both  via  medical  specialists and  patient organizations, stakeholders and their conscious or unconscious  bearers lowered more and more the thresholds, raised the bar of therapeutic targets, expanded prevention relegating it to a mantra slogan, devoid  of any  beneficial effect on health, but very useful for those who have to sell something to someone. The invention of new “diseases,” the illusion of being able to always prevent the development of complications, has led States or Third Party Paying  to try rationing care via a progressive increase in bureaucratic procedures and copayments, that take time away from care to patients. The result of this inflation of the  tasks is the need to overcome the pattern of the individual physician, and move towards  a model of  territorial medicine  socio-epidemiological-based  in which many general practitioners, paediatricians,  and sometimes also some other specialists, work  all together  to deliver standardized care, controlled by nurses on the  basis of rigid  protocols, focusing on models of specialized care of the individual diseases. The risk is to loose completely the deepest sense of the complexity  and of  the time-continuum dimension of the personal care. At the same time the hospital is becoming increasingly reserved  for acute patients, discharging the burden of  chronic care management (more and more increasing, because of aging population and  the inability of medicine to heal) on family doctors and families, left without resources to deal with a real  biblical plague.


The economic crisis plaguing many western  countries  makes unbearable  the weight of this situation, especially in the absence of  provisional  funds to manage disability, and  threatens to blow up the universal health care system  ( 11-15).   But in addition to these professional, economic and organizational aspects exists a problem of strategic perspective. The need to have evidence pushed towards a cure based on the reductionist  method  applying  the theorem of Pareto  that identifies the few factors that explain most of the variance in diagnosis and treatment of diseases.   With such a model  it is possible  to cure  70-80  percent of the population,  but the personalized care is another thing. There are clinical and biological factors (not just human or social) which are very important in a single person and unimportant in a population because they are rare. These factors are not assessable and correctable in complex multifactorial condition by the application of reductionist models, but through the application of the “System Medicine”, an approach which borrows from molecular   biology  the ability to evaluate a large number of variables each of which has little weight, but which, taken together, makes the difference in individuals ( 16-18).  This is even more true  if one considers that the family medicine  does not cure specific diseases, but  persons with multiple problems connected to each other and modulated by the family and society environment. 


All of these requirements, to which the general practitioner is unable to resist because he does not possess economic resources, political influence, and visibility in the media, should be taken into account in the training of future family physicians.

In the training  process  it should  therefore be necessary to implement also theoretical and practical skills to conduct first level diagnostics in primary care facilities (ultrasound, doppler spirometry, for example) and to deal with the diagnostic anticipation expectation that comes, often wrongly misled by media, aimed  to reduce patients hospitalization. 


In addition, the need for complex territorial organizational models  also makes it necessary  to learn the rudiments of managerial and human resource management. Family and social disintegration, poverty back, loneliness of the elderly, blur the boundaries of social and health problems in a continuum that needs to be dealt with knowledge of the tools of social security and the possibilities offered by telemedicine in its various forms: from remote monitoring to remote diagnostics (i.e.  Whole System Demonstrator preliminary results ( 19).

And finally there ought not  be lacking the techniques that confer  future family physicians  the  ability to communicate not only in doctor-patient relationship, but also with media, in order to get the attention needed to influence  public opinion and beliefs of citizens towards health  objectives  really achievable  and sustainable  and to support models of medicine truly personalized. 

Paraphrasing Edgar Morin  ( 20 ),  the agenda of the next training family doctors should be more  geared to Pascal than to Descartes. The more general practice will be strong, not only from the point of view of the social perception of the value of individual physicians, but also  of  the awareness  of identity, the more  it will  be able to develop its own paradigms and fight those the stakeholders are trying to implement.






1)The Impending Collapse of Primary Care Medicine and Its Implications for the State of the Nation’s Health Care: A Report from the American College of Physicians January 30, 2006 available from:

2) Petersen L, Woodard L, Urech T, Daw C, Sookanan S.: Does pay for performance improve the quality of health care? Ann Intern Med2006;145:265-72


3)Serumaga B, Ross-Degnan D, Avery A J, Majumdar S R, Zhang F, Soumerai S B: Effect of pay for performance on the management and outcomes of hypertension in the United Kingdom: interrupted time series study. BMJ 2011;342:d108


4)Greenhalgh T, Stramer K, Bratan T, Byrne E, Russell J, Hinder S, Potts H: THE DEVIL’S IN THE DETAIL Final report of the independent evaluation of the Summary Care Record and HealthSpace 7th May 2010 avalaible from:


5)Nick trigle: Should doctors be ‘agents of the state’? BBC News, February 18, 2008 available from:


6)Ted Ritter: Police to be allowed searches of national database of NHS patient records.  February 28, 2008 available from:


7)Kate Devlin: Patients’ medical records go online without consent. The Telegraph March 9, 2010  available from:


8)Rebecca Smith: Doctors’ outcry over plan to sell patient records The Telegraph March 3, 2009

available from:


9)Meldrum H, Black J, President Carter P, Bown S, Tomkins C, Field S, Maryon-Davis A, Black C D, : Letter to Jack Straw, Justice Secretary, UK. The Telegraph March 3 2009

available from:


10)Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.)


11)Pammolli F: Demography, sustainability, and growth – Notes on the future of the European Social Market Economy

available from:


12) Ageing Working Group (2012), “The 2012 Ageing Report – Economic and budgetary projections for the 27 EU Member States (2010-2060)”, EU Commission, Brussels.

13) International Monetary Fund (2010), “Long-Term Trends in Public Finances in the G-7 Economies”, IMF, Washington DC. 

14) Health at a glance 2011: OECD indicators 23 Nov 2011 DOI:10.1787/health_glance-2011-en 

15) Health: spending continues to outpace economic growth in most OECD countries. JUNE 30 , 2011 avalaible from: 

16) Ahn AC, Tewari M, Poon CS, Phillips RS (2006) The limits of reductionism in medicine: Could systems biology offer an alternative? PLoS Med 3(6): e208. DOI: 10.1371/journal.pmed.0030208

17) Ahn AC, Tewari M, Poon CS, Phillips RS (2006) The clinical applications of a systems approach. PLoS Med 3(7): e209. DOI: 10.1371/journal. pmed.0030209 DOI: 10.1371/journal.pmed.0030209

18) Clermont G., Auffray C, Moreau Y, Rocke D M, Dalevi D, Dubhashi D, Marshall D R, Raasch P, Dehne F, Provero P, Tegner J, Aronow B J, Langston M.A, Benson M:  Bridging the gap between systems biology and medicine. Genome Medicine 2009, 1:88 doi:10.1186/gm88


19) Steventon A, Bardsley M, Billings J, Dixon J, Doll H, Hirani S, Cartwright M, Rixon L, Knapp M, Henderson C, Rogers A, Fitzpatrick R, Hendy J, Newman S, for the Whole System Demonstrator Evaluation Team: Effect of telehealth on use of secondary care and mortality: findings from the Whole System Demonstrator cluster randomised trial. BMJ 2012;344:e3874


20) Edgar Morin:  Les Sept savoirs nécessaires à l’éducation du future. Paris, Seuil, 2000.