The MMG crisis is explained in five phases

by Giuseppe Belleri


Dear Director,
The general practitioner has been living in a period of unrest since the beginning of the century, manifested in a collective emotional climate characterized by a mixture of resentment, demotivation and resignation due to a loss of role that has sociocultural roots, due to some trends also outlined.

1. The evolution of Medidina is driven by the subdivision into subsystems that pushes towards an increasing division of labor, in an attempt to address and reduce biological and ecosystemic complexity with a specular segmentation of knowledge and practices.

The proliferation of specializations means that “the response of the specialist always tends to prevail over that of less differentiation” (Ardigò, 1990) with obvious implications for the patient-doctor-medicine-specialist relationship triangle. Functional differentiation carries the risk of divergence between acute hospital practices and the holistic management of chronicity in the territory (Asioli, 2019). With this interpretive key we can read the “residual” profile of the general practitioner, not a specialist par excellence, proposed as a passive executive employee.

2. The simplification paradigm is the cultural background to the trends described above (Morin, 1993). There are two pillars: the disjunction principle and the reduction principle. To know an object one must first disconnect it, separate it from the environment: knowledge is all the more solid the more decontextualized and standardized, while the variety, uniqueness and complexity of relationships are disruptive factors for the development of technical rationality (Schoen, 1994).

According to the reduction principle, to know an aggregate of parts it is enough with an exhaustive knowledge of its elementary constituents from which the behavior of the set can be deduced. In the history of medicine these principles have inspired the development of hospital care, where there is a separation between the patient and the living environment, functional to the knowledge and effectiveness of treatments, mediated by the pathophysiological interpretation in the organ, tissue or molecular structures. .

3. Technoscientific development pushes the profession towards a segmentation around specific diagnostic and / or therapeutic techniques (Ardigo, Mazzoli, 1994) that marginalizes the generalist, by nature unspecialized with a vocation of holistic, biopsychosocial and cultural approach.

At the same time, the positive WHO definition of health in 1948, replacing the negative with the absence of disease, has fueled expectations of global well-being in the face of a public offering that is struggling with the state crisis. budget, which involved implicit rationing based on moderator tickets, lengthening of waiting lists, and recourse to the private diagnostic and pharmaceutical market.

The continuous relaunch of market supply induces more demand in a circle of self-amplification, by a mixture of defensive motivations and mediated medicalization (Domenighetti 2007, pp. 114-117):
– from the downward revision of the thresholds of the biological parameters that define “the pathological” with proliferation of risks;

– from the generalization of the early diagnoses perceived by the population as synonymous with recovery;

– from the attribution of the status of “disease” to the conditions that are part of the normal biological process of life (disease disease);

– from the promotion of efficiency expectations towards the medical company that go beyond any reasonable scientific evidence.

4. The spread of the Internet has reduced the information asymmetry between doctor and patient in proportion to the disintermediation offered by the network and the decline of paternalism. This translates, on the one hand, into greater patient autonomy that has become “demanding” and demanding, to the instrumental use of revocation, and on the other hand into expectations of efficacy that favor bypass. of primary care in favor of specialized responses. In a complementary way, the decision-making autonomy of the doctor is conditioned by the so-called “administered medicine”, constituted by the normative and prescriptive limitations for the control of the health expenditure.

5. Finally, in the macrosystemic aspect, the interference of the two counterpowers intensified, which counteracted the autonomy / traditional dominance of medicine: on the one hand the liberal and mercantile economy, represented by private insurance companies and large organizations. for profit, and on the other hand the bureaucratic-managerial drift of “administered medicine” into welfare systems. As the sociologist of complexity Edgar Morin observed, health workers are “victims of both a neoliberal policy, which is widely applied to privatize and atrophy public services, and a hyperbureaucratized state management that is increasingly subject to pressure from powerful lobbies ”(Morin 2020, p.45).

The result of these contributing causes is the decline of authority and professional autonomy in a context of widespread unease over the loss of a relationship characterized by trust, deference and respect, which undermines the very basis “the legitimacy of biomedicine itself as an exclusive modality “. the provision of health care “(Giarelli, 2000); in the extreme phenomenon of the” disposable doctor “is manifested liquid medicine characterized by the instability of the care relationship, subject to increasing tensions or open conflicts that weaken motivations and professional dedication to mass desertion.

Giuseppe Belleri
Mmg retired

June 22, 2022
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