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Received: 30 April 2020
| Revised: 24 May 2020
| Accepted: 27 May 2020

DOI: 10.1111/eci.13303

ORIGINAL ARTICLE

The changing face of family medicine in the COVID and

post-COVID era

Ignazio Grattagliano1,2 | Alessandro Rossi1 | Iacopo Cricelli3 | Claudio Cricelli1

1
Italian College of General Practitioners
and Primary Care, Florence, Italy
Abstract
2
Family Medicine, English Medical This article describes the prospective changes and the fundamental values of the re-
Curriculum, University of Bari, Bari, Italy lationships between family doctors, patients and community according to an ethical-
3
Health Search, Italian College of General social concept of medicine. New aspects of the organization of the activity and of the
Practitioners and Primary Care, Florence,
roles of family doctors are reported in order to build hypotheses pointing to a modern
Italy
and efficient management of patients in the coming the post-COVID era.
Correspondence
Ignazio Grattagliano, Italian College of KEYWORDS
General Practitioners and Primary Care, Via COVID, family medicine
del Sansovino 179, Florence 50142, Italy.
Email: [email protected]

1 | IN T RO D U C T ION hypotheses for the management of patients in the coming fu-

ture (Tables 1 and 2).
In the last decade, family doctors (FD), mainly devoted to
the management of elderly and multi-morbid people, have
become increasingly involved in managing patients under in- 2 | GENERAL REM ARK S
novative therapy and by dealing with electronic health record
systems providing faster connection with patients and other As the COVID-19 crisis appears and presses the whole medi-
health workers. This new format of assistance, combined cal system, both specialists, emergency and FD, are having
with administrative and new regulations, results in consid- to prioritize acute cares.3 Accordingly, both primary care and
erable innovation. In Italy, FD take care of over-14 years old hospital medicine had to work to determine what care must
individuals and are mainly organized in small groups of phy- go on and what can be delayed, rescheduled, cancelled or
sicians connected to a database network1,2 covering care in a performed remotely in order to protect physicians and pa-
ratio of 77/100.000 inhabitants (specialists are 185.000 for all tients and to find the best way to treat patients, COVID-19
60 million of Italians). included. In this scenario, FD play a critical role in easing
The SARS-CoV-2 pandemic arrival found the health sys- the burden on the acute-care system by facilitating the early
tems of most countries unprepared and forced the Ministers identification of cases and by helping to amplify the key mes-
of Health to assembly specific task forces to coordinate in- sages to people.
terventions, Italy included. Changes in the family medicine In these days, the pressure of the working world aimed
(FM) assistance were inevitable. at reopening activities after the imposed lock-down has put
This article analyses the existing and the prospective FD in the position to be potential providers of information
changes of the fundamental values of the relationships be- on the epidemic to governors and public administrators by
tween doctors, patients and society according to an eth- giving element of orientation and support for economic de-
ical-social concept of medicine. In short, we examine new cisions (Table 1). The skills in the suspicion of disease and
aspects of the organization and roles of FM in order to build the role as a "sentinel" of the health status of the community

© 2020 Stichting European Society for Clinical Investigation Journal Foundation

Eur J Clin Invest. 2020;50:e13303.  wileyonlinelibrary.com/journal/eci | 1 of 5

https://doi.org/10.1111/eci.13303
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T A B L E 1 (A) Subjects requiring special attention by family outbreak and are of great interest for public health, scientific
doctors in the phase 2 of COVID pandemic; (B) Special measures to and political uses (Figure 1B). This network, named COVID
be applied
Search, has the dual function to provide population data mon-
A itoring and being useful to the development of public health
Over-70 y old people strategies and may serve as decision-making to support phy-
Patients with complex conditions: sicians in their clinical and epidemiological surveillance with
• Transplanted and immunosuppressed
the final aim to contain the epidemic.4
• Oncological during radio-chemotherapy
• Leukaemic or with other myelopathies
• Haemodialytics
Under-70 y old subjects with: 3 | THE ROLE AND ACTIVIT Y OF
• Chronic heart disease FD DURING PANDEM IC
• Chronic respiratory diseases
• Chronic kidney disease In this scenario, the new vision of FM as the first build-
• Chronic liver diseases ing block of surveillance is a consequence of the attributed
• Chronic neurological diseases
function of public health to FD since they interface with the
• Physical and mental disabilities
• Diabetes
individuals in their family and within social contexts. This
• Chronic myelopathies role is consistent with what FD have done in the context of
• Immunodepression from diseases or medications the Covid emergency often shifting the attention from an ad
• Great obesity personam approach to a wide glance at the community to ful-
B fil interaction tasks with other health figures (ie Prevention
Promotion of voluntary mass vaccination against flu and Department workers, Covid deputed hospitals). Working as
pneumococcal pneumonia for all over-50 y old subjects a "sentinel," FD are aimed at getting to know the population
Capillary proximity people tracking: and tackling emerging problems directly pointing to the heart
• In-depth capillary direct knowledge of individuals, micro-
of the society and the community.
communities and extended communities
How these changes are perceived from people and how do
• Real-time detection of population data
• Continuous direct contact in real time with all the Italian they will influence the doctor/patient relationship? Indeed,
population during this epidemic, FD have resumed the close relationship
• Integration of medical records with Covid-related information with the patients, but the general question regarding if and
• Integrated epidemiological observation networks how their protection represents an objective limiting of the
• Application of algorithms for clinical diagnosis prior to activity in front of a potential Covid patient asking for a visit
laboratory findings, based on major and minor criteria, remains a difficult to answer question.
integration of clinical with laboratory criteria
One important ethical problem highlighted by the pan-
• Automatic identification of close contacts of certain or very
probable cases (family members, cohabitants) by computer
demic is the iniquity in the face of a non-uniformity of welfare
programs and health programmes among European countries: indeed, as
a general principle, the right to health must be the same for all
and cannot fail to take into consideration both the safety of the
represent a working system of great utility for the National physicians and that of their assisted people. In addition, ineq-
Health Systems and the Governments in terms of actions to uity has been noted in the management of FD’s activity. The
lessen the risk of pandemic by using systems of (tele)-moni- unfairness that is invoked in the welfare organization is found
toring (Figure 1A). In this view, FD can usefully guide peo- in the event of disparities in the care models among European
ple towards specific intervention by means of communication countries.5 Another crucial and critical aspect regards the dif-
strategies and active involvement in the education of the ferent collaborative models existing between primary care and
masses at all levels. the hospital, for the home care of paucisymptomatic COVID
Therefore, in the face of the COVID epidemic, the role of patients, as well as for the post-hospitalization setting for stabi-
FD is fundamental for monitoring the population in order to lized but not yet healed patients.
minimize the risk of infection (Table 1). A network organiza-
tion of FD equipped with tools necessary for clinical gover-
nance may help to quantify and characterize individuals with 4 | THE CHANGING
clinical diagnosis of COVID-19. RELATIONSHIP BET WEEN FD A N D
In Italy, every day, over 2600 FD caring near 4 million PATIENTS
people anonymously register all the Covid-19 cases by a soft-
ware integrated with the electronic medical record. These Since this is not the time anymore to bring in office rela-
data work in support of a potential monitoring of epidemic tively healthy patients for blood pressure check or for routine
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GRATTAGLIANO et al.    3 of 5

T A B L E 2 Suggested procedures for the management and charge The application of artificial intelligence and the consequent
taking of non-COVID patients by Italian primary care physicians in the use of telemedicine tools for remote detection or monitoring
phase 2 of COVID pandemic
of biological parameters and clinical surveillance will replace
Non-deferrable patients (Acute conditions) the medical examination, thus creating an exclusively, albeit
• Telephone triage with application of scores and rating scales not exhaustively, virtual relationship. With the application of
• Decision for calling emergency/home visit/outpatient visit/ both telemedicine and online drug prescription, the range of
treatment indications (telephone feed-back at 12-24 h)
patients’ distribution in the town may be even enlarged and
Patients with chronicity the distance from the FD’s office increased.
New forms of charge taking:
• Stratification of condition severity
• Identification of goals to be achieved
• Identification and application of working tools 5 | NEW COM PETENCES FOR F D
• Scheduling of actions to be carried out (patient empowerment/ DURING A PANDEM IC
care giver, pre-established tele-(audio) phonic appointment,
telematic reception, compilation of shareable diaries,…) FD act in the balance between treatment and prevention, sur-
• Remote control of therapeutic adherence, consultation by veillance and monitoring, in the face of objective difficulties
telephone for the detection parameters to be monitored (blood that are encountered in these settings.
pressure, oxygen saturation, blood sugar,…)
Now, the Covid epidemic has reevaluated the position of
• Listening and psychological support of the patient and of the
caregiver
the FD which is not only the doctor of chronicity but also,
• Ethical and deontological aspects of the virtual/tele-audio-visual they must do active surveillance. Therefore, a reconfigura-
medical examination tion of the FM also to define new ethical and deontological
• Certification of disease not in the presence of the patient parameters is necessary, pointing to an unexplored identity.6,7
Fragile patients FD are becoming not only the doctors of the person but also
New forms of charge taking: of the community and not only as a sentinel but also in a
• Stratify and identify patients in advance (Charlson Index, context of public health; that is they regain their role in com-
Rokwood Scale, Frailty Index) munity hospitals, no longer intended as an intermediate care
• Assess all the needs
structure for chronicity, but also a place where discharged
• Tele-Monitor and report
patients who still need to stay before returning at home or in
residency. In this coming new era, the two independent forms
blood tests, a much better solutions are to be planned and, of assistance and care systems, hospital and primary care, are
in general, one is to invite patients to get home monitor and necessary called to a new coexistence through a progressive
transmit readings to doctors (Table 2) by the use of different integration to refine new roles. This is particularly import-
electronic platform systems. This measure is inevitable; in ant for elderly and fragile patients (ie people with import-
fact, while before the epidemic, the relationship between doc- ant disabilities and/or multiple chronicity with a significant
tors and patients was personal and confidential, now and in reduction of autonomy) to whom the FD's approach should
the future, the doctor will have an investigative role in history consider the different social and health situations: elderly pa-
of contacts, in indoor and outdoor life habits, and therefore tients living with a caregiver, patients who live alone or in a
even more confidentiality is required. The need for creating a closed community with or without a family behind them. For
new patient medical report is configured. The first evaluation all these different conditions, recommendations and engage-
is made by telephone or audio-visual tools, making the doctor ments should be prepared differently and at least a part of
and patient safe; next, the doctor will decide if it is enough them should actively involve FD.
to have a valid approach or does the patient needs a direct Additional roles and competences for FD in such an
examination (at home or in the office). Telemedicine and emerging situation are to communicate and spread correct in-
the application of scores and scales of evaluation will be in- formation, educational messages, preventive measures with
creasingly used. These points would entail a radical revision authoritativeness and by discarding fake news.
of the concept of "medical examination": the experience of
these days is teaching us that the medical examination in our
crowded offices, in many cases can be replaced in a way that 6 | THE POST-ACUTE PHASE
is sometimes even more effective by the application of alter-
native forms of contact with patients and with an optimal use The high and unacceptable number of lives lost among FD, who
of resources. The traditional concept of "medical examina- had to visit patients with bare hands and had to invent a role and
tion," intended as the necessary presence of the doctor and the assign themselves tasks, imposes drastic prevention measures,
patient in the same place, should be of course reviewed since widespread dissemination of information and specific training
it is frankly anachronistic and largely outdated by the facts. (also for the office staff). In Italy, to date, the overall mortality
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4 of 5    GRATTAGLIANO et al.

(A)
Region Expected threshold Monday Tuesday Wednesday Thursday Friday
Map of Italian Regions
day 1 day 7 cases Graphic cases Graphic cases Graphic cases Graphic cases Graphic

(B)
FD characteristics Patients characteristics
FD (n) Geographical distribution of the Daily incidence of COVID-19 cases
cases by region and province

Suspected cases (n)

Confirmed Covid-19 cases (n)

Confirmed Suspected Incidence distribution according to age and gender
SARS-CoV-2 SARS-CoV-2
infection (n) Males Females
infection (n)

Percentage change during last 7 days

Hospitalized Covid-19 cases (n) Confirmed Suspected

SARS-CoV-2 SARS-CoV-2
pneumonia (n) pneumonia (n)

Percentage change during last 7 days

F I G U R E 1 A, Monitoring activity for new COVID-19 cases according to Italian regions (COVID Search). Green colour for regions with
new patients below the estimated threshold (better trend) and red for those over such a threshold (worsening trend). The threshold is calculated
by using the last available pseudo-R and the number of new registered cases at the beginning of the week. The trend is obtained by comparing the
daily threshold related with the number of days from the beginning of the week. B, Detailed report from COVID Search with specific data of all
registered COVID-19 patients including age, gender, number of suspected or confirmed cases, home management or hospitalization. FD, family
doctors

from COVID is 13.5% with over 26,500 health workers in- 7 | FINAL CONSIDERATIONS
fected, and 51 out of 150 deaths among doctors were FD.
Following the acute epidemic phase, FD should pay special The reconfiguration of the FM and the new roles covered by
attention to the return infections and post-acute complications FD during the pandemic phase and for the post-pandemic era
by acting with all the clinical and instrumental safeguard orga- must be designed yet, although many aspects have been forc-
nization against the transmission of the infection from unknown edly carried out during the epidemic. However, several major
carriers. Also moving to the stabilization phase, in which pre- points need to be taken into the account. One of them is how
vention will prevail, FD should encourage correct lifestyles and to face virtual medicine and virtual doctor? These are aspects
activate flu and pneumonia vaccination of the masses in view of technological evolution that the pandemic has brought us
of the return of the colder months which are normally favouring to the fore, directly projecting the actual modern medicine
flu viruses with possible new epidemic waves. into a post-modern evolutionary medicine. This reconfigured
Valid prevention may be implemented by pointing to con- medicine should never lose its natural connotation which con-
trol systems and people surveillance. In this way, any early templates that the doctor always visits his patient in a direct
suspected patients will allow the opportunity to have a fast or artificial way. To avoid dehumanization of the relation-
diagnosis, an early treatment and timely efficient application ship, these passages should be clearly explained and stated in
of isolation procedures, all efforts to be planned until an ef- order to be progressively accepted by the patient.8 Some ad-
fective vaccine will be identified. vantages, however, will appear and regard dematerialization
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GRATTAGLIANO et al.    5 of 5

of prescriptions, reduced bureaucratization and contacts with 3. Chen N, Zhou M, Dong X, et al. Epidemiological and clinical charac-
specialists by sharing medical records, thus producing facili- teristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan,
China: A descriptive study. Lancet. 2020;395(10223):507-513.
tations for the patient.
4. World Health Organization (WHO). Home care for patients with
New applied rules and deontological norms aiming at suspected novel coronavirus (2019-nCoV) infection presenting
evaluating and managing these innovative concepts are with mild symptoms and management of contacts. Interim guid-
mandatory in order to legally protect FD from these new vi- ance. 2020 [updated January 2020]. https://www.who.int/publi​catio​
sions of the work including the direct relationship between ns-detai​l/home-care-for-patie​nts-with-suspe​cted-novel​-coron​aviru​
doctors and patients and between FD and specialists.9 In this s-(2019-nCoV)-infec​tion-prese​nting​-with-mild-sympt​oms-and-
view, it remains fundamental that the value of managing in- manag​ement​-of-contacts. Accessed May 22, 2020.
5. Greenhalgh T, Koh GCH, Car J. Covid- 19: a remote assessment in
novation should not be managed by it, but by translating
primary care. BMJ. 2020;368:m1182.
from simple to advanced technology, artificial intelligence
6. Mash B. Primary care management of the coronavirus (COVID-19).
should enable all these passages just working as a connect- S Afr Fam Pract. 2020;62(1):a5115.
ing role. 7. Gostin LO, Friedman EA, Wetter SA. Responding to COVID- 19:
how to navigate a public health emergency legally and ethically.
CONFLICT OF INTERESTS Hastings Cent Rep. 2020;50(2):8-12
The authors declare no conflict of interests. 8. Shankar M, et al. Humanism in telemedicine: connecting through
virtual visits during the COVID-19 pandemic. Ann Fam Med. 2020.
(Covid Collection), April 14.
ORCID
9. Ahmed S, Kelly YP, Behera TR, et al. Utility, appropriateness, and
Ignazio Grattagliano https://orcid. content of electronic consultations across medical subspecialties.
org/0000-0002-8991-4313 Ann Intern Med. 2020;172(10):641-647.

R E F E R E NC E S
1. Filippi A, Vanuzzo D, Bignamini AA, et al. The database of Italian How to cite this article: Grattagliano I, Rossi A,
general practitioners allows a reliable determination of the preva- Cricelli I, Cricelli C. The changing face of family
lence of myocardial infarction. Ital Heart J. 2005;6:311-314. medicine in the COVID and post-COVID era. Eur J
2. Cricelli C, Mazzaglia G, Samani F, et al. Prevalence estimates
Clin Invest. 2020;50:e13303. https://doi.org/10.1111/
for chronic diseases in Italy: exploring the differences between
eci.13303
self-report and primary care databases. J Public Health Med.
2003;25:254-257.