Between medical prescriptions and social prescriptions: the cloven patient…

It is well known that the patient is the object of attention of different health professionals such as mainly doctors and nurses, being the focus of clinicians mainly to the biomedical aspect (Arthur Kleinmann, The Illness Narratives: Suffering, Healing, And The Human Condition) rather than to the other parts, the psychological, social and spiritual ones.

Another known feature in Italy is the growing of CME accredited specialties, i.e. health professions subject to Continuing Medical Education, with hundreds of specialties and under medical specialties (cardiology, urologists, pneumology, infectious diseases, neurology, etc.). It is not clear how in this context, which should include an integrated management of the ill person, the social worker, and the counselor are out of this list of possible roles of the ECM.

Another fact is that Italy has an average age of 51 years in the medical profession, with the “call” to work back to offer medical service of retired doctors, to the detriment of the possible inclusion of young doctors, who are exploited instead with project contracts, often hired by cooperatives, and in other situations of precariousness. Senior doctors” over 65 years of age are called, they are poorly paid, as they already have a pension, while young doctors are not allowed in. Let’s not be surprised if our Italian young doctors prefer foreign countries as a place to go for working.

Meanwhile, the Great Administrative Leviathan, the symbol of the sea monster that led the English philosopher Thomas Hobbes to compare his strength with the absolute power of the State continues to destroy talent while preserving the administrative job, and so the figures of bureaucracy in Italy, at least in the public health care sector is embarrassing: from a 30% in hospitals in Northern Italy to a 50% in Southern Italy, with peaks where it is clear that the administration is nothing more than a absorber to our “Article 1” of the Constitution, our Republic is based of job. However the Big Leviathan is untouchable, immovable: although the paper stamps have given way to electronic certifications, and the staff has followed the right computer training, in fact administrative people continues to have their contract indefinitely, and not trained to be rotated in places where there are huge gaps in welfare. We are not talking about highly complex clinical services, but about social care, from taking meals at home for the elderly, to organizing relief holidays for people with disabilities, or working to make the places of care more beautiful.

Meanwhile, the doctors are precarious in the emergency room, with contracts renewed every six months and if it were not for their enormous vocational and missionary spirit, the acute health care, that of saving people’s lives would stop. The Leviathan continues undaunted to swim in the sea of immobilist politics.

If hopefully, the patient’s body is treated on a mission basis, the situation of the social services is more dramatic: too often they have become places of bureaucratic fulfillment for the application of disability benefits, with complicated forms required by the great Leviathan. In this analysis much more than the nuances of divergent practices from region to region, but the oceans of diversity between regions where welfare works in a substantial and non-formal way and others where, apart from cards, either by mail or by mail, the void takes over (not even the form).
That resources are scarce is a clichè that we have been chasing after as a mantra since the late 1980s, and another clichè was that resources have not been well managed. This is true indeed, bad management, self-defense of administrative management, a fortresses of top medical positions, now increasingly senior, with a huge difficulty in passing on the witness of clinical practice to young people: the deans sometimes have not made the young generation to become autonomous enough for fear of losing their role, prestige and power.
The patient is recalled, in politics and partitocratci health care, the week before the elections, as well as in the cities mayors the week before the election start to make promises of clean air and build bike paths.
Hopefully, there are oases, places where the management is enlightened, where one breaks away from the dictates of Leviathan and brings into the health resorts other professionals who bring together the clovede patient. Philosophers come in to talk about existential issues such as health and illness, artists and art therapists come in to use art as a model of care – it is proven from a neuroscientific point of view that works and transmits well-being, singing teachers come in to teach patients with lung diseases to breathe while singing, and still experts in mindfulness (what our generation once called Yoga and that was renamed with an English term to facilitate the access to places of care and management), which bring benefits through meditation on the here and now of the ille patients, and beyond, in the health care providers.

And although not very acknowldeged, alongside medical prescriptions there are social prescriptions, so social workers, educators, art therapists bring people with physical and mental disabilities to museums and art workshops, where they can express their creativity: here, the brain in the meanwhile releases endorphins and serotonin. Social prescriptions are born in the UK, we may like it or not, a country that not only founded the national health service in the nineteenth century but has paid particular attention to the development and inclusion of other professions that care for the other part of the patient, that of the psyche, the soul, and whatever impacts the body.

Although in the UK, especially now, they are going through a time of crisis, partly due to strategic hesitation with the Brexit, and even here the first one to pay is the public welfare systems, those systems are so well organized because inclusive on the basis is the bio-psycho-social and spiritual model.
The strategy for not “halving” the patient is to establish a figure they call the “facilitator”, who activates the correct professions as the correct prescriptions (social and/or medical) according to individual need: a bit like what twenty years ago there was a role called the Case Manager, who however had a much more clinical role and less caring one. The case manager was the result of a philosophy based on “Disease Management”, a standardized diagnostic and therapeutic process system developed by both economists and health professionals, also considering Evidence-Based Medicine. In the UK there is the Society of Art Therapy, Music Therapy and even Sound Therapy: and the latter is called the Royal Society of Sound Therapy. In short, they believe in these disciplines, they study them with a scientific bases they and have “real” dignity.
Today, for us scholars of Medical and Scientific Humanitas , we know quite well the reductionism of the word Disease – disease in the biomedical sense – and we must shift our attention to Illness management, or rather to the care of the sick person in all the many aspects, body, soul, values, passions, activities, ties, emotions, beliefs.

Maybe that’s why Disease Management has partially failed as well as EBM has partially failed: the dissected “cloven” patient is not treated in her/his wholeness, while an inclusive approach becomes scientifically proven and works.

In Italy there are outpatient clinics based on narrative medicine, which are a bit of a “facilitator”: let’s wait for the results. More than dedicated structures, it would be nice to train the staff of the big Leviathan to do less bureaucracy and become “facilitators”, or more, tomorrow, through training, music therapists or art therapists, maybe finally acknowledging these professions in the ECM. We all should educated them do a more qualified job too.

And last but not least: with all the art and music that we have in Italy, beyond our clinical skills for which our doctors go to work abroad and immediately win competitions for deep preparation why do we have to miss this opportunity? We bring together the patient’s parts, we put the bureaucracy on a diet, and we include in a transdisciplinary way the languages of care and their professionals.

Maria Giulia Marini

Epidemiologist and counselor in transactional analysis, thirty years of professional life in health care. I have a classic humanistic background, including the knowledge of Ancient Greek and Latin, which opened me to study languages and arts, becoming an Art Coach. I followed afterward scientific academic studies, in clinical pharmacology with an academic specialization in Epidemiology (University of Milan and Pavia). Past international experiences at the Harvard Medical School and in a pharma company at Mainz in Germany. Currently Director of Innovation in the Health Care Area of Fondazione ISTUD a center for educational and social and health care research. I'm serving as president of EUNAMES- European Narrative Medicine Society, on the board of Italian Society of Narrative Medicine, a tenured professor of Narrative Medicine at La Sapienza, Roma, and teaching narrative medicine in other universities and institutions at a national and international level. In 2016 I was a referee for the World Health Organization- Europen for “Narrative Method of Research in Public Health.” Writer of the books; “Narrative medicine: Bridging the gap between Evidence-Based care and Medical Humanities,” and "Languages of care in Narrative Medicine" edited with Springer, and since 2021 main editor for Springer of the new series "New Paradigms in Health Care."

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